Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in 2 of 9 records reviewed.
Client # 8 was evaluated on August 23, 2023. There was documentation that the evaluation was sent to another drug and alcohol treatment provider; however, there was no consent to release form signed by the client prior to disclosure of this information.
Client # 9 was evaluated on August 21, 2023. There was documentation that the evaluation was sent to a probation officer; however, there was no consent to release form signed by the client prior to disclosure of this information.
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Plan of Correction
Chief Clinical Officer (CCO) has developed a Release of Information(ROI) form specifically for agents of the court, Probation/ Parole Officers, to be reviewed with and signed by all individuals seeking "Drug & Alcohol Evaluations" as related to criminal complaints. A new policy and procedure has been added and all staff has been trained on this requirement. All individuals seeking a "Drug & Alcohol"or similar evaluation by court order, will be required to sign a limited ROI specific to the information disclosed in evaluation, giving the service provider approval to send the final evaluation letter to an agent of the court. Hard copies of all ROIs used for in this capacity will be kept in a 3-ring binder, in a locked filing cabinet, in the office of the CCO. The binder will be reviewed bi-weekly at compliance management meetings. |