Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in one of ten records reviewed.
The findings include:
Ten client records were reviewed on January 8-9, 2015. All were reviewed for informed and voluntary consent forms. The facility failed to document informed and voluntary consents in one client record, specifically record, #2.
Client #2 - Consent to release dated September 10, 2014 for the client's pharmacy failed to have the name of the pharmacy listed on the consent to release form. The facility only documented "my pharmacy" on the consent to release form which is not the name of the pharmacy used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2 has been discharged from services, therefore a new consent form is unable to be completed. The Facility Director will oversee that all staff are re-educated via staff meeting to complete all consents thoroughly, to include the name of the person, agency or organization to whom the disclosure is made. Office Administration will ensure ongoing compliance by checking all releases for completion prior to scanning the documents into the electronic record. The Quality Improvement Department will also monitor for ongoing compliance via random chart audits. |