Observations
Based on a review of client records, the facility failed to ensure that there was documentation of written acknowledgment by the client that the client had been made aware of all of their rights in client record # ' s 1, 2, 3, 4, 5, 6, and 7.
The clients signed a written acknowledgement of receiving client rights within a handbook, which is given to clients upon admission.
The client rights in the handbook does not include the following:
1. 709.30 (3) - "The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record".
2. 709.30(4) - "Clients have the right to appeal a decision limiting access to their records to the director".
3. 709.30(5) - "Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records".
4. 709.30(6) - "Clients have the right to submit rebuttal data or memoranda to their own records."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director/designee will oversee that the PCS client rights document is revised to include statements 709.30(3), 709.30(4), 709.30(5), and 709.30(6). This revision will be completed by 3/29/2019 and included in intake packets for any new clients. All existing clients will be provided a revised copy of the client's rights by 4/26/2019. To ensure ongoing compliance, the Quality Improvement Department will conduct random chart audits to monitor that each client record contains documentation of written acknowledgment by the client that the client has been made aware of all of his/her rights. |