Observations
Based on a review of client records during the annual licensing inspection conducted on June 14 - 15, 2016, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of twelve records reviewed.Client # 3 was admitted into treatment on September 22, 2015. The facility faxed the client's name and a treatment progress update to a medical provider on March 9 and April 19, 2016. No consent to release information was documented for this provider. Client # 9 was admitted into treatment on May 20, 2015 and discharged on October 1, 2015. The facility released the client's name and diagnosis during an online request for counseling authorization to the funding entity on May 28, 2015. No consent to release information was documented for this funding entity. Client # 12 was admitted into treatment on December 1, 2015 and discharged on March 23, 2016. The facility released the client's name and diagnosis during an online request for counseling authorization to the funding entity on December 3, 2015. No consent to release information was documented for this funding entity. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility/Project Director will ensure that informed and voluntary consent from clients for the disclosure of information contained in the client record is obtained. The Facility/Project Director will ensure that an informed and voluntary consent will be obtained prior to the release of any confidential information to any outside entity. Facility/Project Director will retrain staff during 6/22/16 weekly staff supervision on the completion of consents to release information. Facility/Project Director will complete monthly client chart audits to ensure staff are documenting consents to release information. |