Observations
Based on the review of client records and an interview with the facility director, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of client information in five of six client records. The findings include: Eight client records were reviewed on September 9-10, 2010. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of client information. The program provides family group sessions were various family members of the clients attend as the family members schedule permits. Six client records required an informed and voluntary consent from the client in regards to family group sessions. The facility failed to obtain an informed and voluntary consent for the disclosure of client information in client records # 1, 2, 4, 5 and 6. In client record # 1, the client was admitted on July 19, 2010. The client attended family group sessions on August 31 and 24, 2010. There was no documentation that a release of information had been obtained by the client to release the client's identity to the group's family members, nor was there documentation that the client had been given the option of not attending the family group sessions. In client record # 2, the client was admitted on July 19, 2010. The client attended family group sessions on July 20, August 3 and September 7, 2010. There was no documentation that a release of information had been obtained by the client to release the client's identity to the group's family members, nor was there documentation that the client had been given the option of not attending the family group sessions. In client record # 4, the client was admitted on June 8, 2010. The client attended family group sessions on June 15 and June 22, 2010. There was no documentation that a release of information had been obtained by the client to release the client's identity to the group's family members, nor was there documentation that the client had been given the option of not attending the family group sessions. In client record # 5, the client was admitted on January 11, 2010. The client attended family group sessions on March 2 and March 9, 2010. There was no documentation that a release of information had been obtained by the client to release the client's identity to the group's family members, nor was there documentation that the client had been given the option of not attending the family group sessions. In client record # 6, the client was admitted on February 25, 2010. The client attended family group sessions on March 9 and April 20, 2010. There was no documentation that a release of information had been obtained by the client to release the client's identity to the group's family members, nor was there documentation that the client had been given the option of not attending the family group sessions. An interview with the facility director on September 10, 2010 confirmed that the clients had not completed releases of information for the family group sessions.
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Plan of Correction
A new release/acknowlegement form has been developed by the Program Director specifically for release of each client's identity to the group's family members. Each client attending family groups will be required to sign the release prior to entering family group. All staff will be trained by the Program Director on the implementation and reason behind the new release. The office coordinator will assure each client who participates signs the release and are placed in the permanant client record. Any deficiencies will be brought to the attention of the Program Director. |