Observations
Based on a review of seven client records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information in one of the seven records reviewed. Client #5 was admitted on July 18, 2025, and was still active at the time of the inspection. There was documentation that a disclosure was made to a mental health provider on September 04, 2025; however, the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information until November 12, 2025. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
- Release will be continued to be monitored and staff will be reminded to double check releases before calling any outside source.
The importance of collaboration and coordination will be addressed ongoing, but importance of actual patient signature will be double checked.
-Release was signed by the patient after the date that the crisis occured.
This will be reviewed in our staffing meeting on 2/12/26. All staff will be reminded of the protocols of releases and importance of them being signed. Releases will be signed at the beginning of each session and crisis situation to avoid this from happening in the future.
This process will be monitored by our clinical director and through ongoing random case file reviews that are done internally. |