Observations
The facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in one of seven client records reviewed on November 6, 2019.
Client # 5 was admitted February 12, 2019 and discharged September 3, 2019. The facility director confirmed the client's name and authorization of treatment services request was released to the funding entity without the written consent of client # 5.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It will be the job of the Facility Director to train each JADE staff member in regards to company protocol for following disclosure of information. The Facility Director will work with the internal JADE Billing team to ensure anytime an insurance change is being made within the electronic medical record we are alerting the primary therapist of said change via direct message and leaving a message on the patients message board that a new consent will be due. Said message will remain in place until the consent is signed. This will be done during the first agency wide staffing following licensing, dated for 11.27.2019. The clinical supervisor will ensure the deficiency does not recur by conducting random client record audits to confirm consents are being signed for required funding entities. |