Observations
The facility failed to document an informed and voluntary consent from the client prior to the disclosure of information contained in the client record in two of fourteen client records reviewed on May 14 - 15, 2018.
The client's name and diagnosis was released to the medical insurance company by fax for prior authorization of medication in the following client records.
Client # 10 was admitted on November 14, 2017. The disclosure occurred on December 21, 2017. In addition, the client's name, diagnosis and prescription information was disclosed to the pharmacy on December 21, 2017 without the client's written consent.
Client # 12 was admitted on April 4, 2018. The disclosure occurred on April 26, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director met with nursing staff and counselors during staff meeting on 5/29/18 to review requirement of obtaining written release of information for medical insurance for clients receiving Vivitrol. Clinical supervisor will monitor all Vivitrol charts for the appropriate release of information. |