Observations
Based on the review of client records, the facility failed to document that the client was offered a copy of their consent to release forms.
The findings include:
Eleven client records were reviewed on January 23, 2014. A copy of a client consent shall be offered to the client and a copy maintained in the client records. Documentation showing that the client was offered a copy was not documented in the following client records, # 1, 2, 4, 5, 6, 8, 9, 10 and 11.
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Plan of Correction
The Facility Director will oversee that all staff are re-educated to document that the client was offered copies of his/her consent to release forms. The Director of Quality Improvement will conduct random chart reviews to ensure ongoing compliance. |