Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which documented the purpose of the disclosure and the specific information to be disclosed in one of eleven client records reviewed. The findings include: Eleven client records which required documentation of an informed and voluntary consent were reviewed on October 8, 2015. The facility failed to obtain an informed and voluntary consent which documented the purpose of the disclosure and the specific information disclosed in client record # 9. Client # 9 was admitted into treatment on 8/7/13 and was still active at the time of the inspection. A consent to release information form for a Buprenorphine program, which was signed and dated on 8/6/14, did not document the purpose of the disclosure and the specific information disclosed. The client's record documented a letter that was mailed to the Buprenorphine program on 8/24/14, regarding the client's discharge. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/8/15 the outpatient supervisor advised the outpatient counselor of the invalid consent and importance of completing the consent completely and including the purpose and the specific information to be released. Effective 10/8/15 the outpatient counselor was advised to not release any further information to the Buprenorphine Doctor on client #9 until a valid consent was signed. On 10/8/15 client#9 was contacted via phone and advised consent wasn't filled out correctly and that at the next appointment on 11/16/15 she would be asked to sign another consent for her Doctor by the outpatient counselor. Monthly the outpatient supervisor will review the outpatient files with the Coudersport counselor to ensure valid consents. This will begin 11/18/15. Quarterly at the outpatient department meetings the outpatient supervisor will review the elements of a valid consent with all the clinical staff. Yearly at All Agency meetings the outpatient supervisor will provide a training on the elements of a valid consent. |