INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 2 - 4, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on January 29, 2007.
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Plan of Correction
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Chart #2 disclosed Client identifying information was disclosed to an insurance company from client record #2 without having a consent to release information form signed by the client.
Letters addressed to "To whom it may concern" were included in client records # 3 and 4. The person or agency that was the intended recipient of the information was not identified and therefore a corresponding release of information could not be confirmed.
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Plan of Correction
A consent to release information form for this client will be obtained. A mandatory staff meeting was held on 01/04/07 to address this issue. The clinical supervisor will review charts when signing off making note to ensure these releases are properly obtained.
This was also addressed during the 01/04/07 mandatory staff meeting. Letters will no longer be addressed to "To whom it may concern" and will addressed to either the client or the appropriate individual. A release will be obtained if it is not addressed to the client. The clinical supervisor will review charts when signing off making note to ensure this gets done properly. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
A treatment plan update was missing from client record #3.
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Plan of Correction
This was addressed and clarified during the mandatory staff meeting on 01/04/07. All treatment plans will be reviewed and updated at least every 60 days. The clinical supervisor will review this when signing off on charts to ensure these plans are in the charts when due. |