Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in six of 10 client records.
The findings include:
Sixteen client records were reviewed on March 1 - 2, 2012. Ten client records were reviewed for documentation of informed and voluntary consents from the client. The facility accessed the Internet site of a funding entity to confirm the client's current insurance coverage. Prior to releasing client information to this funding entity, the facility failed to document an informed and voluntary consent from the client in client records # 3, 4, 6, 7, 8 and 12.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The facility director and clinical supervisor will provide training to clinical staff regarding the need for appropriate informed and voluntary consents for all information being released, including for the verification of benefits. The clinical staff will be provided with the appropriate consent and will review with all of the patients in their next sessions to acquire consent. The Clinical Supervisor and the Facility Director will actively review and meet with clinical staff regularly to ensure this standard is being met. |