Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in three of eighteen client records reviewed.Client # 10 was admitted to the outpatient activity on August 16, 2021 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. Client # 11 was admitted to the outpatient activity on August 24, 2021 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. Client # 13 was admitted to the outpatient activity on August 6, 2021 and was discharged on October 8, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. This is a repeat citation from the June 11, 2021 licensing inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor has audited all active charts and has distributed a list to front desk staff so they are aware who needs to sign consent to release information documents. These patients will be notified by the assigned therapist that it is required that they come on site to sign all outstanding documents by 12/31/2021 and failure to do so could result in discharge from the program. Clinical supervisor will do spot checks of these patient's charts on a weekly basis to track progress.
All SUD evaluations were in person as of 9/7/21 so any consent or ROI after 9/7/21 will have original "wet" signatures. |
Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in six of eighteen client records reviewed. Client # 5 was admitted to the partial hospitalization activity on September 9, 2021 and was discharged on September 27, 2021. The release of information form to a legal office was signed and dated by the witness on September 10, 2021, but the form did not document the dated signature of the client. Client # 10 was admitted to the outpatient activity on August 16, 2021 and was still active at the time of the inspection. The release of information form to an emergency contact was signed and dated by the witness on August 12, 2021. Also, the release of information forms to the funding source and the urinalysis laboratory were signed and dated by the witness on August 13, 2021. Additionally, the release of information forms to various government agencies were signed and dated by the witness on August 16, 2021. However, all of the release forms did not document the dated signature of the client. Client # 11 was admitted to the outpatient activity on August 24, 2021 and was still active at the time of the inspection. The release of information forms to the emergency contact, the funding source and the urinalysis laboratory were signed and dated by the witness on August 24, 2021, but none of the forms documented the dated signature of the client. Additionally, the release of information form to a government agency was signed and dated by the witness on August 25, 2021, but the form did not document the dated signature of the client. Client # 13 was admitted to the outpatient activity on August 6, 2021 and was discharged on October 8, 2021. The release of information forms to the emergency contact, the funding source, and the urinalysis laboratory were signed and dated by the witness on August 5, 2021, but none of the forms documented the dated signature of the client. Additionally, the release of information form to an attorney was signed and dated by the witness on September 24, 2021, but the form did not document the dated signature of the client. Client # 16 was admitted to the outpatient activity on June 10, 2021 and was discharged on September 29, 2021. The release of information form to a parole officer was signed and dated by the witness on September 29, 2021, but the form did not document the dated signature of the client. Client # 17 was admitted to the outpatient activity on June 12, 2021 and was still active at the time of the inspection. The release of information forms to several government agencies were signed and dated by the witness on October 7, 2021, but none of the forms did not document the dated signature of the client. This is a repeat citation from the June 11, 2021 licensing inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor has audited all active charts and has distributed a list to front desk staff so they are aware who needs to sign release of information documents. These patients will be notified by the assigned therapist that it is required that they come on site to sign all outstanding documents by 12/31/2021 and failure to do so could result in discharge from the program. Clinical supervisor will do spot checks of these patient's charts on a weekly basis to track progress.
All SUD evaluations were in person as of 9/7/21 so any consent or ROI after 9/7/21 will have original "wet" signatures. |