Observations
The facility failed to obtain informed and voluntary consent forms for the disclosure of information contained in the client record in ten of ten client records reviewed on December 1-2, 2016.
Ten client records were reviewed. Ten records required an informed and voluntary consent to release client information. The facility failed to obtain an informed and voluntary consent to release information in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 10.
The consent to release information form states that revocation must be in writing. 42 CFR Part 2, Subpart C, subsection 2.31 (a) Required elements, specifies that the following information must be included on the written consent: "(8) A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it." Therefore, as per 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) the consent to release client information form can be revoked by the client at any time and there is no restriction on the manner in which they may revoke it. The facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the clients to revoke consent forms in writing.
In addition, consents to release information to criminal justice authorities were observed to include a statement that the consent could not be revoked. There were no court orders mandating treatment documented for these clients and therefore, the consents could be revoked verbally or in writing at any time.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
VP of Clinical Services revised consents on November 28, 2016 to ensure that all consents contain appropriate elements of a valid consent, including acknowledgement that a copy was offered to the client as well as the ability to revoke consents verbally or in writing. Criminal Justice consent was revised to eliminate statement that consent cannot be revoked. All staff members who deal directly with consents will receive additional training on revisions and completion of consents. Training will be concluded by February 2017 and will be conducted by Regional Clinical Coordinators. Completion of training will be verified by post test completion and monitored by Human resources Coordinators. Compliance of consents will continue to monitored by Vice President of Corporate Compliance and the team of Clinical Coordinators. Clinical Coordinators and Clinical Supervisors will continue to monitor releases weekly when chart monitors are completed. |
Observations
The facility failed to document that a copy of signed consents were offered to the client in ten of ten client records.
Ten client records were reviewed on December 1-2, 2016. All ten client records included at least one signed consent in which the client was not offered a copy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Vice President of Clinical Services revised consents on November 28, 2016 to ensure that all consents contain appropriate elements of a valid consent in the electronic medical record. This included acknowledgement that a copy was offered to the client as well as the ability to revoke consents verbally or in writing. Criminal Justice consent was revised to eliminate statement that consent cannot be revoked. All staff members who deal directly with consents will receive additional training on revisions and completion of consents. Training will be concluded by February 2017 and will be conducted by Regional Clinical Coordinators. Completion of training will be verified by post test completion and monitored by Human resources Coordinators. Compliance of consents will continue to monitored by Vice President of Corporate Compliance and the team of Clinical Coordinators. Clinical Coordinators and Clinical Supervisors will continue to monitor releases weekly when chart monitors are completed. |