Observations
Based on the review of the client records, the facility failed to document an informed and voluntary consent from the client. The consent to release information forms failed to document the purpose for each consent to release information forms in six of six client records reviewed.
The findings include:
Six client records were reviewed on February 11, 2014. Six client records were required to provide an informed and voluntary consent which includes the purpose of disclosure. The facility failed to do so in client records #1, 2, 3, 4, 5 and 6.
Client record # 1- The client was admitted to treatment on November 25, 2013 and was discharged on January 22, 2014. The consent to release information form signed on 11-18-2013 did not include a purpose for the release of information.
Client record # 2- The client was admitted to treatment on September 11, 2013 and was discharged on December 11, 2013. The two consent to release information forms signed on 8-14-2013 and 11-20-2013 did not include a purpose for the release of information.
Client record # 3- The client was admitted to treatment on September 18, 2013 and was discharged on December 17, 2013. The consent to release information form signed on 9-10-2013 did not include a purpose for the release of information.
Client record # 4- The client was admitted to treatment on September 17, 2013 and was discharged on October 10, 2013. The two consent to release information forms signed on 9-12-2013 did not include a purpose for the release of information.
Client record # 5- The client was admitted to treatment on November 6, 2013 and was discharged on February 5, 2014. The two consent to release information forms signed on 10-31-2013 did not include a purpose for the release of information.
Client record # 6- The client was admitted to treatment on October 24, 2013. The consent to release information form signed on 10-9-2013 did not include a purpose for the release of information.
The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
On 2/12/2014 facility director met with office manager and had the phrase : Purpose of Release:
added to all consents to release information forms. All old forms were shredded. The staff was trained by facility director on 2/27/2014 concerning proper documentation of consent form, what constitutes "purpose" of release and the case manger will be responsible for chart reviews to insure documentation is accurate for all consent forms. |