Observations
Based on a review of client records, the facility failed to document a completed consent to release information in two out of seven records reviewed.
Client # 5 was admitted on July 30, 2021 and discharged on November 22, 2021. There was a consent to release form, signed and dated on November 3, 2021 to a funding source, but the consent form did not include documentation that the client was offered a copy of the consent form.
Client # 7 was admitted on December 13, 2021 and was still active at the time of the inspection. There was a consent to release form, signed and dated on January 6, 2022 to a funding source, but the consent form did not include documentation that the client was offered a copy of the consent form.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
- Clinical Supervisors review of the initial inspection findings in All Staff Meeting on 05/10/22 along with discussion of immediate documentation changes needed to ensure compliance
- 05/24/22 ? Teaching and discussion in Group Supervision of DDAP regulations regarding the essential components of a completed consent to release information
- Plan for periodic, targeted review of charts submitted for MD signature to be conducted by Clinical Supervisor for Training and QI. Formal, monthly review of randomly selected charts to be implemented in FY22-23. Detailed plan and system for chart review rubric and procedures to be developed by Clinical Supervisor and Director on 06/21/22 and presented agency-wide in All Staff Meeting on 07/12/22. |