Observations
Based on an administrative review, the governing body failed to make available to the public an annual report, for 2020, which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
RHD will make every effort to ensure the public annual report is available in a timely fashion. The RHD Communication Team is currently in the process of finalizing the annual report for 2020 and once completed will make it available for public viewing. This is expected to occur within the next few weeks. |
Observations
Based on a review of client records, the facility failed to document the dated signature of a client on release of information forms in seven of fourteen client records reviewed.
Client # 1 was admitted to the outpatient level of care on May 3, 2021 and was still active at time of inspection. There were release of information forms to an outside individual, another treatment provider, several government agencies, and a funding source that were all signed and dated by a witness on May 3, 2021; however, the dated signature of the client was not documented on any of the release forms.
Client # 2 was admitted to the outpatient level of care on June 2, 2021 and was still active at time of inspection. There was a release of information form to another treatment provider that was signed and dated by a witness on July 21, 2021; however, the dated signature of the client was not documented on the form.
Client # 3 was admitted to the outpatient level of care on June 9, 2021 and was still active at time of inspection. There were release of information forms to an outside individual, another treatment provider, several government agencies, a physician, and a funding source that were all signed and dated by a witness on June 9, 2021; however, the dated signature of the client was not documented on any of the release forms.
Client # 4 was admitted to the outpatient level of care on June 17, 2021 and was discharged on July 8, 2021. There were release of information forms to an outside individual, another treatment provider, a government agency, a physician, and a funding source that were all signed and dated by a witness on June 17, 2021; however, the dated signature of the client was not documented on any of the release forms.
Client # 5 was admitted to the outpatient level of care on June 15, 2021 and was discharged on July 6, 2021. There were release of information forms to an outside individual, another treatment provider, several government agencies, a physician, and a funding source that were all signed and dated by a witness on June 15, 2021; however, the dated signature of the client was not documented on any of the release forms.
Client # 6 was admitted to the outpatient level of care on June 16, 2021 and was discharged on July 19, 2021. There were release of information forms to an outside individual, another treatment provider, sevarl government agencies, a physician, and a funding source that were all signed and dated by a witness on June 16, 2021; however, the dated signature of the client was not documented on any of the release forms.
Client # 9 was admitted for evaluation services on June 3, 2021 and was discharged on June 16, 2021. There was a release of information form to a funding source, that was signed and dated by a witness on June 3, 2021; however, the dated signature of the client was not documented on the release form.
This is a repeat citation from the annual renewal inspection conducted on March 11, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to provision of telehealth services, this provider did not obtain physical signatures on releases of information. Verbal consent to release this information was provided by clients. The below plan of correction is intended to rectify this issue:
A list of clients seen for OP services and IER services from 03/11/2020 (when verbal consent process began) until present will be pulled from databases to identify clients affected by verbal release provision.
All clients will be contacted to be given the option to: come in person to sign necessary forms, have forms mailed to them (if choosing this option, clients will have to mail forms back via SASE), have forms emailed to them via encrypted message (if choosing this option, clients will need access to print/scan signature items back to staff).
Staff will meet in person with clients who choose this option to review paperwork. Charts will be earmarked prior to visit to identify physical signatures needed.
If clients choose mail/email option, releases of information will be mailed/emailed to client for signature. Staff will review the content of this information again to ensure the client understands the information contained therein.
Documentation will be included in all charts to indicate when client was contacted, which method of delivery they opted for, when the appointment and/or documents were sent to them, and any necessary follow up attempts made.
Moving forward, while still providing telehealth services, therapists will notify clients of any upcoming documentation that is in need of a physical signature and make arrangements based on client preference to obtain signatures. RHD is in the early stages of implementing DocuSign for securing electronic consent.
This plan will prioritize current, active clients. Once those clients have been contacted and signatures obtained, staff will begin outreach to discharged, inactive clients. Due to the nature of this outreach, staff anticipates that there may be a lack of motivation to participate in this process on behalf of the client; therefore, staff will be instructed to document the outreach via documentation provided as part of this plan of correction.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent to release information form was offered to the client in two of fourteen client records reviewed.
Client # 9 was admitted for evaluation services on June 3, 2021 and was discharged on June 16, 2021. There were release of information forms to several government agencies, treatment providers, and an outside individual that were signed and dated by the client on June 3, 2021; however, there was no documentation that copies of any of the forms were offered to the client.
Client # 13 was admitted for evaluation services on June 14, 2021 and was discharged on June 21, 2021. There were release of information forms to a health provider and several treatment providers, that were signed and dated by the client on June 14, 2021; however, there was no documentation that copies of any of the forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The records reviewed were individuals assessed while incarcerated. Due to limitations in the correctional facility, assessors are not able to meet in person with individuals accessing services, only via video visitation; therefore, coordination with the correctional facility to complete all necessary documentation is required. Moving forward, assessors have been informed to ensure that that the client indicates whether a form is offered to them. If they choose to have a copy of the form, staff will request that correctional facility staff provide that copy. RHD Staff will also send a copy to the client's home address to ensure a copy is received by the client. Supervisors will review charts on a regular basis in compliance with the internal chart audit policy. If it is identified that a client has not indicated whether or not they want a copy of a release, supervisor will communicate that to the staff responsible. All new staff will be trained on this process as well. |