Observations
Based on a review of client records and an interview with the clinician, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in client record # 3.
The findings include:
Six client records were reviewed on March 18, 2011 for documentation of an informed and voluntary consent.
The facility did not obtain an informed and voluntary consent for the disclosure of client information in one of six client records, specifically client record # 3.
Client # 3 was a minor seeking treatment.
Client # 3 was admitted to the program on 12/20/10 and at the time of review on 3/18/11 was an active client.
Per review of progress notes and the record of service one family session was held on 12/28/10, both parents were present at the session.
However, when reviewing consents to release forms; a release was not documented for either parent.
An interview was conducted with the clinician.
The clinician reviewed client record # 3 at which time she confirmed that she erroneously failed to obtain a consent form.
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Plan of Correction
The client successfully completed treatment on 3/28/2011.
A release of information was not obtained for the patient's parents, who were the participants in the family session.
A staff training will be held on 5/20/2011 by the Facility Director to review Key Recovery's Confidentiality Policy & Procedure.
A monitor will be added to the Open chart audits that will ensure review of all releases of information.
Audit results will be reported monthly to the Performance Improvement Committee. |