Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client prior to disclosure of information in two of ten client records.
The findings included:
Ten client records were reviewed on March 24, 2015. Ten client records were required to document an informed and voluntary consent from the client prior to the disclosure of information. Client records #3 and 4 did not include a valid informed and voluntary consent prior to the disclosure of information.
Client #3 was admitted to treatment on February 11, 2015. A release of information to family members, signed on February 19, 2015, did not include specific information to be disclosed and the purpose of the disclosure.
Client #4 was admitted to treatment on December 17, 2014. A release of information to an attorney, signed on March 19, 2015, did not include specific information to be disclosed and the purpose of the disclosure. There was also no release of information documented in the client record for the funding source.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Pathway to Recovery Facility Director will review outcome of site visit and confidentiality regulations with regards to release of information with Clinical Director and Supervisor. The Clinical Supervisor will review with clinical staff documentation procedures for consents from the client for the disclosure of information contained in the client record. All clients activated after April 6, 2015 will be in compliance with regulation. The Facility Director will follow and monitor with chart audits to ensure compliance. |