Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent to release client information form in one of eleven client records reviewed.
The findings include:
Twelve client records were reviewed on November 5, 6 and 14, 2013. Eleven client records were reviewed regarding documentation of the release of client information. The facility failed to ensure that an informed and voluntary consent to release client information form was obtained in client record # 12.
Client # 12 was admitted on June 25, 2013 and discharged on July 26, 2013. The record included documentation of a telephone conversation between the client's counselor and the uncle of the client that was dated July 17, 2013. As per the documented phone call, the counselor released information about the client's absences and treatment status. The counselor also agreed to call the uncle again with a status update on the client. The facility failed to obtain an informed and voluntary consent to release information form from the client regarding the client's absences and treatment status. The record included a consent to release information form that was signed by the client that was for emergency purposes only. Specifically, the consent to release information form only allowed the facility to release the nature of the emergency and the location of the client to the client's uncle.
The Facility Director was interviewed on November 6, 2013 and confirmed the findings.
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Plan of Correction
The Clinical Manager conducted a staff meeting on November 19,2013 and included a review of these findings and the regulations regarding obtaining informed and voluntary consent to release client information.
Staff were directed to always check the client's medical record prior to disclosing information to anyone regarding client information. If a completed, written and signed consent is not on file, staff will need to first discuss with the client and acquire a signed consent.
The Clinical Manager is responsible for ensuring that the corrective action is implemented. She will also have the office Administrative Assistant assist in ensuring that the appropriate consents are completed and available for all patient information that is to be disclosed. |