Observations
Based on a review of client records the facility failed to include the name of the person, agency, or organization to whom disclosure is made.
The findings include:
On January 7, 2015 ten client records were reviewed. Ten records were required to contain complete informed and voluntary consents to release information to include the name of the person, agency, or organization to whom disclosure is made.
Client record #10 contained a consent to release information to "my insurance company".
The findings were reviewed with the facility director at the time of the inspection.
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Plan of Correction
The Facility Director will oversee that all staff are re-educated via staff meeting to complete all consents thoroughly, to include the name of the person, agency, or organization to whom the disclosure is made. Office administration will ensure ongoing compliance by checking all releases for completion prior to scanning the documents into the electronic record. The Quality Improvement Department will also monitor for ongoing compliance via random chart audits. |