Observations
Based on a review of client records, qualified service organization agreements and an interview with the facility director, the facility failed to document an informed and voluntary consent or a qualified service organization agreement when releasing urine samples to an outside agency for drug testing in twelve of fifteen client records.
The findings include:
Fifteen client records were reviewed on July 21 - 22, 2010. Urine samples were sent to an outside agency in twelve client records. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Client records # 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 did not include a signed consent to release information nor was a qualified service organization agreement in place for the outside agency.
The facility director was interviewed on July 22, 2010 at approximately 11:30 AM and confirmed the facility did not have a qualified service organization agreement with the agency that conducts drug testing. The facility director also confirmed that informed and voluntary consents had not been completed for clients who were participating in drug testing. The facility director reported a qualified service organization agreement will be obtained with the agency that provides this testing for the facility. The facility director reported that until this agreement is obtained; the counselors will obtain consents from the clients who are participating in drug testing.
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Plan of Correction
On July 22, 2010, Facility Director instructed all counselors to have all current clients sign consents for the laboratory providing drug testing for the facility. Effective July 22, 2010, all clients will sign consents upon initial assessment for the laboratory providing drug testing.
On Aug. 11, 2010, Facility Director submitted a Qualified Service Organization Agreement signed by the Senior Director of Behavioral Health to the outside agency that provides drug testing. Consents will continue to be obtained until such a time that the Qualified Service Organization Agreement has been received from the laboratory providing services.
The QSOA will be renewed with the laboratory every two years.
Until the QSOA is signed and returned, random chart audits will be conducted by the Facility Director to ensure that consent has been obtained from the client for any urine screens that have been sent to the laboratory for testing.
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