Observations
Based on a review of the client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one out of seven client records reviewed.
Client # 3 was admitted on December 14, 2021 and still active at the time of the inspection. There was no signed and dated consent to release information for the funding source and the facility confirmed billing for services.
The finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all requirements regarding confidentiality.
Consent was obtained for the original funding source. The client had just recently changed funding sources and a new consent had not yet been obtained for his new funder. One had been sent out to him to sign but it had not been returned at the time of inspection. It has since been completed and returned. We fully recognize the need for complete and accurate records including the completion of a proper consent form for the funder. Effective 4/14/2022, all staff have been reminded of which consent forms are needed. Consent forms will be regularly reviewed in weekly clinical supervision as well as through random file audits. Director will follow up monthly with clinical supervisors to assure continued compliance.
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