Observations
The facility failed to document written acknowledgement by clients that they had been notified of the right to inspect their own record and that included: the project, facility director or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and that the reasons for removing sections shall be documented in the record; that clients had the right to appeal a decision limiting access to their records to the director; that clients had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records or that the clients had the right to submit rebuttal data or memoranda to their own records in ten of ten client records.
Ten client records were reviewed on August 9, 2016. Client records # 1, 2, 3, 4, 5, 6,7, 8, 9 and 10 did not include written documentation that the client was notified of their rights.
These findings were reviewed with facilty staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |