Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in three of eight client records reviewed.
Client #1 was admitted on January 31, 2025 and was discharged on March 31, 2025. There was a release of information form to a funding source signed and dated by the client on January 31, 2025; however, the purpose of the disclosure was not documented on the release form.
Client #2 was admitted on February 12, 2025 and was discharged on April 3, 2025. There was a release of information form to a funding source signed and dated by the client on February 12, 2025; however, the purpose of the disclosure was not documented on the release form.
Client #3 was admitted on March 13, 2025 and was active at the time of inspection. There was a release of information form to a funding source signed and dated by the client on March 14, 2025; however, the purpose of the disclosure was not documented on the release form.
This is a repeat citation from the December 10, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CCBHC Senior Director and VP of Integrated Care re-trained the care manager on 12/16/2025 after the completion of the DDAP site visit. The training included the importance of documenting the purpose of the disclosure of information on the consent to release information to a funding source. It was reviewed that the clear purpose must be documented on all release forms. The consent forms in client #'s 1, 2 and 3 were reviewed together. The CCBHC Senior Director will monitor this weekly by completing chart audits and reviewing the caseload report. The CCBHC senior director will review her findings with the VP of Integrated Care on a weekly basis during supervision. |