Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in two out of seven records reviewed.
Client #1 was admitted on February 25, 2025, and discharged on August 25, 2025. A consent form signed and dated by the client on February 25, 2025, for a referral organization, did not have documentation that the client was offered a copy of the consent form.
Client #7 was admitted on January 14, 2025, and discharged on July 15, 2025. A consent form signed and dated by the client on January 14, 2025, for a referral organization, did not have documentation that the client was offered a copy of the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project and Facility Director shall train counselors by 12/19/25 to include specifically what additional information may be disclosed when reviewing and completing consent to release information form. We will also train on the documentation of this information. Facility Director will review files monthly to ensure compliance. |