Observations
Based on the review of client records, the project failed to offer a copy of release of information form in one of seven records reviewed.
Client #7 was admitted on July 8, 2025, and was discharged on January 30, 2026. There was no documentation that the client was offered a copy of the release of information form for a probation officer, that was signed and dated by the client on July 8, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Citation / Deficiency:
One patient consent form was found to be out of compliance due to the absence of a completed checkbox indicating whether the patient was offered a copy of the consent and whether the patient accepted or refused.
Corrective Action Taken (Immediate):
The specific record identified in the citation was reviewed by the Program Director and Clinical Supervisor. Staff confirmed that the consent had been explained to the patient; however, the checkbox indicating that the patient was offered a copy was not marked.
Systemic Corrective Action & Methodology:
To ensure ongoing compliance with consent documentation standards, the following actions have been implemented:
1. Staff Training
All clinical staff responsible for intake and consent documentation received mandatory re-education conducted by the Program Director on proper completion of consent forms on April 16, 2026 at a staff meeting. Training specifically emphasized:
a. Review of DDAP regulatory requirements for consent documentation
b. Emphasis on completion of all required fields, including the checkbox indicating whether a copy of the consent was offered and accepted or refused.
c. Expectations for real-time, complete, and accurate documentation
All new hires will receive this training as part of onboarding by the Clinical Supervisor or Program Director
2. Standardized Documentation Process
A standardized Intake and Consent Documentation Checklist was implemented on 4/16/26; staff were provided with the document via email, and the document was placed in our master forms file.
a. The Primary Counselor/Intake Staff is responsible for completing the checklist at the time of the intake to ensure all required documentation elements are addressed.
b. The checklist and documentation are submitted to the Clinical Supervisor or Program Director who verifies all required elements are completed prior to finalizing documentation and signs off on the checklist.
c. Documentation will not be considered complete until all required fields, including checkboxes, are verified.
3. Supervisory Review and Follow-Up
The Clinical Supervisor will conduct weekly chart audits of 100% of new admissions for a period of 60 days to ensure full compliance with consent documentation requirements.
a. Any deficiencies identified will be addressed with the responsible staff member within one (1) business day, including documented supervision, corrective instruction, and re-training if necessary.
4. Ongoing Oversight and Quality Assurance
Following the 60 day review period, the Program Director will ensure continued compliance through monthly quality assurance audits. The Program Director is responsible for oversight of compliance with this standard and will address any trends through additional staff training, increased supervision, or corrective action as appropriate.
Responsible Staff by Position:
1. Primary Counselor/Intake Staff: completion of all intake and consent documentation, including required checkboxes
2. Clinical Supervisor: staff training, weekly audits, and direct supervisory follow-up
3. Program Director: ongoing quality assurance oversight and enforcement of compliance
Timeline for Compliance:
- Staff training/re-education was completed on 4/16/2026
- Checklist Implementation was effective on 4/16/2026
- Weekly supervisory audits initiated on 4/16/2026 and continued for 60 days
The facility will achieve full compliance with this standard by 5/1/2026. Ongoing compliance will be maintained through supervisory audits and the agency's quality assurance processes
Monitoring of effectiveness:
Compliance will be measured by achieving 100% completion of required consent documentation fields in all audited records. Audit findings will be reviewed by the Clinical Supervisor and Program Director. Any deficiencies will result in immediate corrective action, including staff re-training and increased monitoring, to ensure sustained compliance. |