Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of seven client records reviewed.
Client #7 was admitted on May 28, 2025 and discharged on May 28, 2025. There was no documentation that copies of an informed and voluntary consent to release information forms for one treatment facility, two funding sources and two legal entities dated May 28, 2025, were offered to the client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will review this requirement with staff by April 24th 2026 to ensure compliance with 709.28(d) regarding client consent documentation. Staff will be re-educated by April 24th 2026 that a copy of the informed and voluntary consent must be offered to the client and documented in the client record at the time the consent is completed. Clinical Supervisor will conduct monthly reviews of at least two client records to ensure proper documentation is present. Any deficiencies identified will be addressed immediately through corrective feedback and additional staff training to ensure continued compliance. |