Observations
Based on a review of patient records on January 2-3, 2018, the facility failed to obtain an informed and voluntary consent for the disclosure of information in one of eight patient records reviewed.
Patient #3 was admitted to treatment on June 4, 2015 and was discharged on November 28, 2017. The consent to release information for the emergency contact expired on June 4. 2016. An updated consent for the emergency contact was not documented in the patient record covering treatment from June 5, 2016 through November 28, 2017, at the time of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the record in question. All staff were trained on state regulations in addition to internal policy and procedure related to confidentiality/consents on Thursday 1/4/18. Current staff have been informed that all consents are required to be updated on an annual basis. Future staff will be trained by Facility Director, Clinical Supervisor, or Lead Counselor during orientation regarding confidentiality and consents. The Facility Director, Clinical Supervisor and Lead Counselor will ensure compliance is maintained through weekly internal chart audits. Staff will utilize new computerized system (SMART) to track due dates for consents.
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