Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client in three of seven client records.
The findings include:
Seven client records were reviewed on July 22, 2014. All seven client records were required to include an informed and voluntary consent from the client. The purpose was not identified in records #1, 2, and 6.
Client #1 was admitted to treatment on 3-12-2014, and was discharged on 6-11-2014. A release of information for a physician was signed on 3-12-2014, and did not include a relevant purpose of disclosure.
Client #2 was admitted to treatment on 3-11-2014, and was discharged on 6-3-2014. A release of information for a physician was signed on 3-11-2014, and did not include a relevant purpose of disclosure.
Client #6 was admitted to treatment on 4-30-2014. A release of information for a physician was signed on 4-2-2014, and did not include a relevant purpose of disclosure.
The findings were reviewed with the director and were not disputed.
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Plan of Correction
The Executive Director and the Assistant Director will conduct a staff-wide training on confidentiality and how to complete a 5 point release prior to 9/30/14. Each supervisor will conduct 3 chart audits per month per counselor/nurse to ensure releases are completed in an appropriate manner. |