Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in fourteen out of the fourteen records reviewed.
Client #1 was admitted on July 7, 2025 and discharged on August 15, 2025. A release form dated July 7, 2025 to a funder had "other" checked without listing what additional information could be released.
Client #2 was admitted on July 25, 2025 and was still active at the time of the inspection. A release form dated May 21, 2025 to a funder had "other" checked without listing what additional information could be released.
Client #3 was admitted on May 2, 2025 and discharged on May 22, 2025. Two release forms dated May 5, 2025 to a funder and emergency contact had "other" checked without listing what additional information could be released. In addition, five release of information forms dated May 5, 2025 to medical facilities did not list what information could be disclosed.
Client #4 was admitted on July 14, 2025 and discharged on September 5, 2025. A release form dated May 21, 2025 to a funder had "other" checked without listing what additional information could be released.
Client #5 was admitted on May 27, 2025 and discharged on June 27, 2025. Two release forms dated May 23 and May 27, 2025 to a funder had "other" checked without listing what additional information could be released. In addition, five release of information forms dated May 27, 2025 to medical facilities did not list what information could be disclosed.
Client #6 was admitted on May 27, 2025 and discharged on July 3, 2025. Two release forms dated May 27 and May 28, 2025 to a funder had "other" checked without listing what additional information could be released. In addition, four release of information forms dated May 28, 2025 to medical facilities did not list what information could be disclosed.
Client #7 was admitted on July 11, 2025 and discharged on August 27, 2025. A release form dated July 8, 2025 to a funder had "other" checked without listing what additional information could be released. In addition, four release of information forms dated July 11, 2025 to medical facilities did not list what information could be disclosed.
Client #8 was admitted on May 8, 2025 and discharged on June 6, 2026. Two release forms dated May 6 and May 8, 2025 to a funder had "other" checked without listing what additional information could be released. In addition, five release of information forms dated May 8, 2025 to medical facilities did not list what information could be disclosed.
Client #9 was admitted on May 20, 2025 and discharged on July 8, 2025. Two release forms dated May 16 and June 6, 2025 to a funder had "other" checked without listing what additional information could be released. In addition, five release of information forms dated June 6, 2025 to medical facilities did not list what information could be disclosed.
Client #10 was admitted on June 16, 2025 and discharged on August 6, 2025. Two release forms dated June 16 and June 17, 2025 to a funder had "other" checked without listing what additional information could be released. In addition, five release of information forms dated June 17, 2025 to medical facilities did not list what information could be disclosed.
Client #11 was admitted on June 2, 2025 and discharged on August 8, 2025. A release form dated May 3, 2025 to a funder had "other" checked without listing what additional information could be released. In addition, five release of information forms did not list what information could be disclosed. One of the forms was dated May 3, 2025 to a government agency. Four forms were dated June 2, 2025 to medical facilities.
Client #12 was admitted on June 26, 2025 and discharged on August 22, 2025. A release form dated May 22, 2025 to a funder had "other" checked without listing what additional information could be released.
Client #13 was admitted on July 7, 2025 and discharged on September 10, 2025. A release form dated July 8, 2025 to a funder had "other" checked without listing what additional information could be released.
Client #14 was admitted on August 4, 2025 and was still active at the time of the inspection. A release form dated August 4, 2025 to a funder had "other" checked without listing what additional information could be released.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clinical and administrative staff were re-trained on the requirement to obtain and document a completed consent to release information form for each client at admission and prior to any release of information. Audits by the Compliance Coordinator will take place on a monthly basis. |
Observations
Based on the review of client records, the facility failed to document a completed consent to release information form which included a purpose of disclosure in eight out of fourteen records reviewed.
Client #3 was admitted on May 2, 2025 and discharged on May 22, 2025. A release form dated May 5, 2025 to an emergency contact had "other" checked without listing an additional purpose. In addition, five release of information forms dated May 5, 2025 to medical facilities did not list a purpose.
Client #5 was admitted on May 27, 2025 and discharged on June 27, 2025. Five release of information forms dated May 27, 2025 to medical facilities did not list a purpose.
Client #6 was admitted on May 27, 2025 and discharged on July 3, 2025. Four release of information forms dated May 28, 2025 to medical facilities did not list a purpose.
Client #7 was admitted on July 11, 2025 and discharged on August 27, 2025. Four release of information forms dated July 11, 2025 to medical facilities did not list a purpose.
Client #8 was admitted on May 8, 2025 and discharged on June 6, 2025. Five release of information forms dated May 8, 2025 to medical facilities did not list a purpose.
Client #9 was admitted on May 20, 2025 and discharged on July 8, 2025. Five release of information forms dated June 6, 2025 to medical facilities did not list a purpose.
Client #10 was admitted on June 16, 2025 and discharged on August 6, 2025. Five release of information forms dated June 17, 2025 to medical facilities did not list a purpose.
Client #11 was admitted on June 2, 2025 and discharged on August 8, 2025. Four release of information forms dated June 2, 2025 to medical facilities did not list a purpose.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clinical and administrative staff were re-trained on the requirement to obtain and document a completed consent to release information form for each client at admission and prior to any release of information. Audits by the Compliance Coordinator will take place on a monthly basis. |