Observations
The facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in two of ten client records reviewed during the annual licensing inspection conducted on August 22 - 23, 2016.
A consent to release information form was not documented for the funding entity, and the Clinical Director confirmed the facility disclosed the client's name and identifying information during the billing of counseling services provided in client records # 9 and 10.
Client # 9 was admitted into treatment on February 17, 2016 and discharged on May 6, 2016 .
Client # 10 was admitted into treatment on February 22, 2016 and discharged on June 7, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of the compliance issue there was a different staff overseeing that information. New staff was hired and trained and a checklist is in place to monitor compliance with all information. This will continue to be monitored routinely through established departmental compliance monitoring procedures. |