Observations
Based on the review of client records, the facility failed to document a consent to treatment form during the intake procedures in five of ten client records.
The findings include:
Intake and admission procedures are to be completed with clients prior to the start of the treatment process.
Eleven client records were reviewed on February 18-19, 2014. Ten client records were to include a consent to treatment form that was signed by the client as part of the intake procedures. The facility failed to document a consent to treatment form as part of the intake procedures in client records # 2, 3, 4, 5 and 10.
Client # 2 began the treatment process on October 10, 2013 as indicated by the first individual counseling session documented in the record. The facility failed to document the consent to treatment form during the intake procedure as the form wasn't signed by the client until October 14, 2013.
Client # 3 began the treatment process on July 29, 2013 as indicated by the first individual counseling session documented in the record. The facility failed to document the consent to treatment form during the intake procedure as the form wasn't signed by the client until August 22, 2013.
Client # 4 began the treatment process on August 5, 2013 as indicated by the first individual counseling session documented in the record. The facility failed to document the consent to treatment form during the intake procedure as the form wasn't signed by the client until August 19, 2013.
Client # 5 began the treatment process on October 29, 2013 as indicated by the first individual counseling session documented in the record. The facility failed to document the consent to treatment form during the intake procedure as the form wasn't signed by the client until November 19, 2013.
Client # 10 began the treatment process on August 6, 2013 as indicated by the first individual counseling session documented in the record. The facility failed to document the consent to treatment form during the intake procedure as the form wasn't signed by the client until August 14, 2013.
The Clinical Supervisor was interviewed on February 19, 2014 and did not dispute the findings.
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Plan of Correction
Since the Site Visit a new policy was developed and implemented instructing staff to have the client sign a consent to treatment form at the time of the client first intake session.
The Clinical supervisor will review new client charts over the next month to see that staff are following the new policy.
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