Observations
Based on a review of client records, the facility failed to document the name of a person, agency, or organization to whom the disclosure was to be made to on consent to release information forms in one of fourteen client records reviewed.
Client # 6 was admitted on May 29, 2025 and was discharged on July 17, 2025. Release of information forms to several government agencies were signed and dated by the client on May 29, 2025; however, none of the consent forms included the name of a person, agency, or organization to whom the disclosures were to be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
For client #6, who has since been discharged, the existing forms with pending information were removed and kept consents where information was updated and applicable in the chart.
All clinical and Clinical Supervisor involved in the preparation and review of consent forms received refresher training on the importance of complete documentation, including the requirement to specify the recipient's name, agency, or organization on all consent to release information forms following inspection on 9/18/25 including removing any pending consents upon completion of updated informational if required and if not, ensuring consent is complete once information is full and upload to chart.
The Clinical Supervisor, and Facility Director as needed, will oversee the correction process and ensure that all steps are completed that ongoing monitoring is maintained. All consents will be audited before uploading after completion to ensure there are no pending or incomplete consents. Any pending will be re-audited and removed when updated if applicable and consents completed when all information is applicable, will be submitted to Clinical Supervisor to audit and then check all previous consents are removed if pending if applicable.
Plan is put in effective immediately 9/17/2025.
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