Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from one client for the disclosure of information contained in the client record that included a dated signature of the client as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
Client #5 was admitted on June 8, 2020 and was discharged on July 9, 2021. Two informed and voluntary consents from the client for the disclosure of information contained in the client record for a government agency and a medical office signed and dated by a witness on June 16, 2020 did not include a dated signature of the client. The informed and voluntary consent stated " COVID 19/ Telehealth. "
Two additional informed and voluntary consents from the client for the disclosure of information contained in the client record for a funding source and a medical office signed and dated by a witness on June 9, 2020 did not include a dated signature of the client. The informed and voluntary consent stated " COVID 19/ Telehealth. "
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director has determined that all future assessments of incoming clients will no longer be conducted via telehealth services. All initial assessments will be done face-to-face which will provide the opportunity for all necessary signatures, including client consents, to be obtained. The agency's telehealth policy will be updated to reflect this change. As the only employee of the agency staff training will not be needed. All clients will be informed of this policy upon the initial screening if they were to request telehealth services. If clients refuse to proceed with an in-person assessment, they will be offered the numbers of facilities which may provide a telehealth assessment. This change in policy shall take place immediately as of the date of this plan or correction. |