Observations
Based on seven of seven client records reviewed, the facility failed obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record for clients # 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted on September 23, 2021 and was still active at the time of the inspection. Based on a review of the client's record, there was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. Confirmation from the facility indicated funding was provided for drug and alcohol treatment.
Client # 2 was admitted on August 2, 2021 and was still active at the time of the inspection. Based on a review of the client's record, there was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. Confirmation from the facility indicated funding was provided for drug and alcohol treatment.
Client # 3 was admitted on September 22, 2021 and was still active at the time of the inspection. Based on a review of the client's record, there was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. Confirmation from the facility indicated funding was provided for drug and alcohol treatment.
Client # 4 was admitted on September 28, 2021 and was still active at the time of the inspection. Based on a review of the client's record, there was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. Confirmation from the facility indicated funding was provided for drug and alcohol treatment.
Client # 5 was admitted on June 14, 2021 and was discharged on October 11, 2021. Based on a review of the client's record, there was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. Confirmation from the facility indicated funding was provided for drug and alcohol treatment.
Client # 6 was admitted on June 17, 2021 and was discharged on September 1, 2021. Based on a review of the client's record, there was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. Confirmation from the facility indicated funding was provided for drug and alcohol treatment.
Client # 7 was admitted on July 2, 2021 and was discharged on August 26, 2021. Based on a review of the client's record, there was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. Confirmation from the facility indicated funding was provided for drug and alcohol treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project's informed and voluntary consent form will be modified to included disclosure of information of the funding source by the Project Director. Staff will be trained on the modification to the consent and all Clients will have the form presented by 1/8/22, by the Facility Director. The Facility Director will review files to ensure compliance monthly. |