Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in two of four client records.
The findings include:
Four client records were reviewed on May 21, 2013. Four client records were required to include an informed and voluntary consent from the client prior to the disclosure of information.
Client record #1 - The client was admitted on 12-28-2012, and was discharged on 2-1-2013. Information was disclosed to a judge via a letter documented on 12-28-2012, but there was no written consent to release information form permitting the facility to release information to the judge. Information was disclosed to a sponsor via a sponsor agreement documented on 1-15-2013, but there was no written consent to release information permitting the facility to release information to the sponsor.
Record #4 - The client was admitted on 3-4-2013. Information was disclosed to a sponsor via a sponsor agreement documented on 4-3-2013, but there was no written consent to release information permitting the facility to release information to the sponsor.
The findings were reviewed with the project/facility director and were not disputed.
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Plan of Correction
Releases of information will be completed by the counselor for all sponsors at the time the counsler meets with the client and sponsor to sign sponsor agreements. The sponsor will only be given information concerning whether or not the client is in treatment. The clincal supervisor will review during chart reviews.
Releases will have specific names on the release when sending information to the Judge. The clinical supervisor will review all releases. |