Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed in two of seven client records.Client #1 was admitted on November 2, 2021 and discharged on April 5, 2022. Client record #1 had a signed release of information documented November 2, 2021 that did not include specific information to be disclosed.Client #4 was admitted on December 2, 2021 and discharged on April 28, 2022. Client record #4 had a signed release of information documented December 2, 2021 that did not include specific information to be disclosed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Supervisor will review the process for appropriate completion and documentation of releases of information in staff training with all Substance Abuse Services Therapists and support staff personnel. Support staff will be responsible for reviewing consents for release of information prior to importing ROI into the electronic health record, and return inappropriately completed ROIs to the Clinical Supervisor for review with therapist and correction with individual providing consent. |