Observations
Based on a review of client records and an interview with the clinical supervisor and facility director, the facility failed to obtain an informed and voluntary consent from the client prior to disclosure of client identifying information in four of five client records, as required by regulation.
The findings included:
Five client records were reviewed on April 20, 2010. Per regulation, the project shall obtain an informed and voluntary consent from the client prior to the disclosure of any client identifying information. Five client records required an informed and voluntary consent from the client. The facility failed to obtain an informed an voluntary consent prior to the disclosure of client identifying information to the referral source in client records # 1, 2, 3 and 5.
Client # 1 was admitted on May 26, 2009. On May 26, 2009, a letter of activation including the clients name and start date for substance abuse treatment was sent to the referral source. An informed and voluntary consent form was signed after the letter was sent on June 3, 2009.
Client # 2 was admitted on May 7, 2009. On May 7, 2009, a letter of activation including the clients name and start date for substance abuse treatment was sent to the referral source. An informed and voluntary consent form was signed after the letter was sent on May 13, 2009.
Client # 3 was admitted on June 16, 2009. On June 16, 2009, a letter of activation including the clients name and start date for substance abuse treatment was sent to the referral source. An informed and voluntary consent form was signed after the letter was sent on June 17, 2009.
Client # 5 was admitted on February 22, 2010. On February 22, 2010, a letter of activation including the clients name and start date for substance abuse treatment was sent to the referral source. An informed and voluntary consent form was signed after the letter was sent on February 23, 2010.
On March 20, 2010 the clinical supervisor and facility director were interviewed at which time it was confirmed that the letters of activation were sent prior to when the informed and voluntary consent form was signed by the client.
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Plan of Correction
Pathway to Recovery Facility Director will review outcome of site visit and confidentiality regulations on April 26, 2010. The clinical supervisor will not send letter of activation to referral source until the consent for release of information is signed by the client. All clients activated after April 26, 2010 will be in compliance with regulation. The Facility Director will follow and monitor with chart audits to ensure compliance. |