Observations
Based on the review of client records, the facility failed to document a completed consent to release information in four out of twelve records reviewed, as there was a form that was missing purpose of disclosure.Client #2 was admitted on December May 2, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on May 4, 2022 to a medical provider. Client #12 was admitted on January 21, 22 and was discharged February 7, 2022. There was a consent to release form, signed and dated on November 16, 2021 to an insurance company.Client #13 was admitted on February 8, 2022 and was discharged May 5, 2022. There was a consent to release form, signed and dated on December 15, 2021 to an insurance company. Client #14 was admitted on December 27, 2021 and was discharged April 11, 2022. There was a consent to release form, signed and dated on December 27, 2021 to a medical provider. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor has reviewed and re-trained staff on 5/23/2022 on how to fully and appropriately complete consent forms. Clinical supervisor has reiterated that forms may not be backdated, and that forms must be signed and entered on the same day. Clinical supervisor also reviewed and re-trained all staff to ensure that new consent forms are completed for outpatient stays, as it is a separate level of care/admission from their inpatient stay.
All primary therapists will be redoing the active patient's consents that are incorrect by 5/27/2022. Clinical supervisor will be doing chart checks on all active patients the week of 5/30/2022 to ensure that all consents for active patients are correctly done.
Moving forward, clinical supervisor will be conducting chart checks on a biweekly basis to ensure all protocols for consents are being followed. Additional training and follow up will take place with staff members as needed.
Clinical supervisor will also be meeting with EMR administrator to implement safeguards in the consents, which will not allow consents to be saved without them being completed entirely. |