Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in one of seven client records reviewed.
Client # 7 was admitted on November 18, 2021 and was discharged on March 11, 2022. The release of information forms to the funding source and the primary care physician were signed and dated by the witness on November 5, 2021, but neither form documented the dated signature of the client.
This is a repeat citation from the June 24, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As this individual has been discharged, there is no ability to obtain a live signature in this case. From this point forward:
- Each individual opened to SUOP will continue to meet with PATH staff in-person on the day of or prior to the day of admission to the program to provide live signatures on all Authorizations, Consents and Releases of Information- effective 7.6.22 and this is ongoing and will be reviewed in daily case conference, by supervisory staff the day following the scheduled appointment.
- All previously verbally consented Releases of Information obtained in the MHOP program will be updated with live signatures or voided if no longer necessary by writing a specific note in the Administrative CM Note tab in the SUOP episode in the EHR-effective 7.6.22 this is ongoing and will monitored in Daily case conference by supervisory staff.
- All staff with interaction with individuals in the SUOP program will receive training regarding obtaining live signatures on any Authorizations, Consents and Releases
o Current staff will be trained by 8/6/2022
o New Staff will be trained within 30 days - this will be monitored & verified through PATH Learning Management Reporting System.
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