Observations
Based on the review of client records, the facility failed to document a completed consent to release information in two out of seven records reviewed, as there were forms that were missing required information.
Client #1 was admitted on August 31, 2021 and was still active at the time of the inspection. There was a consent to release form, signed and dated on July 13, 2021 to their emergency contact but the consent form did not include whether a copy of was offered to the client.
Client #4 was admitted on November 17, 2021 and was still active at the time of the inspection. There were consent to release forms, signed and dated on December 29, 2021 and January 12, 2022 to two providers but the consent forms did not include whether a copy was offered to the client.
The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
In order to comply with regulation 709.28. Confidentiality. (d) A copy of a client consent shall be offered to the client and a copy maintained in the client record, the following plan of correction will be implemented; Clinical Supervisor and Assistant Clinical Supervisor will conduct a clinical and support staff training on March 11th, 2022 and review regulation and reason for deficiency. Once it is ascertained that staff understand the regulation, the importance of following the regulation, and why the program was cited, staff will be provided with a brief training on consent completion. As part of this training, each staff member will engage in a role-play to practice compliance with the regulation and demonstrate to co-workers their ability to effectively complete this task.
Clinical staff will be asked to review consents for release of information for active clients, and if deficiency is found, clinical staff will review consents with the identified client, and offer copy of form.
Clinical Supervisor, Assistant Clinical Supervisor, Client Care Coordinator and Front Office manager will conduct a follow-up client chart audit within 30 days of 3/11/2022 training to ensure compliance with regulation 709.28 (D).
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