Observations
Based on a review of client records, and an interview with the facility director, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in one of six client records.
The findings include:
Six client records were reviewed on April 14, 2010. Six of those client records were required to include an informed and voluntary consent from the client prior to the disclosure of information. Record #6 had documentation of a contact attempt made in reference to the client prior to a consent to release information form being signed by the client.
Client #6 was admitted on July 15, 2010. documentation of a contact form completed on November 19, 2010 at 1:38 pm. The contact form was to inform of a contact attempt made to the client's mother. A consent form for the person referenced on the form was not completed until January 31, 2011
A interview was conducted with the facility director on April 14, 2010 to confirm the lack of proper consent documentation.
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Plan of Correction
Informed and voluntary written consent will be obtained from clients prior to facailty staff disclosing information. All copies of consents to disclose informatation will be in the client record. Clinical Supervisor will review the confidentially regulations with all staff in a meeting. Staff will sign off that they are aware of this regulation. To further insure compliance the Clinical Supervisor and Division Director will review client records on a monthly basis. Additionally, counselor in question atteneded the BDAP confisentiality training on 12/17/2010, to further insure compliance with this regulation. |