Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on release of information forms in six of fourteen client records reviewed.
Client # 2 was admitted to the partial hospitalization activity on July 17, 2024 and was active at the time of the inspection. A release of information form to a parent was signed by the client on July 22, 2023, but the form did not include the purpose of the disclosure.
Client # 6 was admitted to the partial hospitalization activity on December 4, 2023 and was discharged on January 8, 2024. A release of information form to a parent was signed by the client on July December 4, 2024, but the form did not include the purpose of the disclosure.
Client # 7 was admitted to the partial hospitalization activity on March 21, 2024 and was discharged on April 22, 2024. A release of information form to a government agency was signed by the client on April 10, 2024, but the form did not include the purpose of the disclosure.
Client # 9 was admitted to the outpatient activity on January 8, 2024 and was active at the time of the inspection. A release of information form to a parent was signed by the client on July December 4, 2024, but the form did not include the purpose of the disclosure.
Client # 10 was admitted to the outpatient activity on April 22, 2024 and was active at the time of the inspection. A release of information form to a government agency was signed by the client on April 10, 2024, but the form did not include the purpose of the disclosure.
Client # 12 was admitted to the outpatient activity on January 31, 2024 and was discharged on June 26, 2024. A release of information form to a parole officer was signed by the client on January 31, 2024, but the form did not include the purpose of the disclosure.
This is a repeat citation from the September 13, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 08/13/2024, during a routine Outpatient Clinical Team Meeting, Clinical Director gave a brief review of requirements for properly completing ROI's in our EMR. Additionally, the staff members involved in not properly completely ROI'S were put on performance improvement plans.
Lead Counselor will audit 30% of all new admissions to assure that ROI's are being completed in their entirety and no sections are being overlooked.
All ROI's not properly completed were corrected in the respective clients' next individual counseling session. They have all been corrected as of 9/12/24. For clients no longer in treatment whose ROI's were not filled out properly, those are not able to be corrected unfortunately. |
Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in seven of fourteen client records reviewed.
Client # 4 was admitted to the partial hospitalization activity on February 13, 2024 and was discharged on March 17, 2024. The release of information form to a funding source was signed by the client on February 15, 2024; however, there was no documentation indicating a copy of the consent was offered to the client.
Client # 5 was admitted to the partial hospitalization activity on November 28, 2023 and was discharged on December 26, 2024. The release of information forms to a funding source, an emergency contact, a primary care physician, an external counselor, another treatment provider, and a behavioral health provider were all signed by the client on November 28, 2023; however, there was no documentation indicating a copy of any of the consent forms were offered to the client.
Client # 6 was admitted to the partial hospitalization activity on December 4, 2023 and was discharged on January 8, 2023. The release of information forms to a funding source, a volunteer organization, a parent, a recovery house, and a primary care physician were all signed by the client; however, there was no documentation indicating a copy of any of the consent forms were offered to the client.
Client # 8 was admitted to the partial outpatient activity on December 26, 2023 and was active at the time of the inspection. The release of information forms to a funding source, an emergency contact, a primary care physician, an external counselor, another treatment provider, and a behavioral health provider were all signed by the client on November 28, 2023; however, there was no documentation indicating a copy of any of the consent forms were offered to the client.
Client # 9 was admitted to the outpatient activity on January 8, 2024 and was active at the time of the inspection. The release of information forms to a funding source, a volunteer organization, a parent, a recovery house, and a primary care physician were all signed by the client; however, there was no documentation indicating a copy of any of the consent forms were offered to the client.
Client # 11 was admitted to the outpatient activity on March 18, 2024 and was discharged on April 14, 2024. The release of information form to a funding source was signed by the client on February 15, 2024; however, there was no documentation indicating a copy of the consent form was offered to the client.
Client # 12 was admitted to the outpatient activity on January 31, 2024 and was discharged on June 26, 2024. The release of information forms to a funding source, a parole officer, and an emergency contact were all signed by the client on January 31, 2024; however, there was no documentation indicating a copy of any of the consent forms were offered to the client.
This is a repeat citation from the September 13, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 8/28/2024, it is now automatic that the ROI form cannot be completely processed in our EMR without a copy of the form being offered to the client. This is a required box that must be selected in order for the form to be signed off on and completed in the system. |