Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in four of nine records reviewed.
The findings include:
Nine client records were reviewed on February 18, 2016. All were reviewed for informed and voluntary consent forms. The facility failed to document if the client was offered a copy of the informed and voluntary consent forms.
Client #2- The facility failed to document on the consent to release dated February 9, 2016 for a treatment agency whether or not the client was offered a copy of the consent.
Client #5- The facility failed to document on the consent to release dated February 17, 2016 for a treatment agency whether or not the client was offered a copy of the consent.
Client #6- The facility failed to document on the consent to release dated July 24, 2015 for a treatment agency whether or not the client was offered a copy of the consent.
Client #8- The facility failed to document on the consent to release dated January 15, 2016 for a treatment agency whether or not the client was offered a copy of the consent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Inpatient Treatment met with all clinical and administrative staff who are responsible for completing client consent forms on 2/26/16. The Director of Inpatient Treatment clarified Colonial House policy in regards to PA Code 709.28(d). Staff members were shown the specific area of the consent that must be completed in order to provide proof that the client was offered a copy of the consent. All staff members signed a copy of the presented information to acknowledge their understanding of the current policy expectations. The Director of Inpatient Treatment will monitor for compliance through chart audits and supervision. |