Observations
Based upon observation and a physical plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
A physical plant inspection was conducted on January 5, 2012 at approximately 1:30 PM.
There were two fire extinguishers located on the women's unit.
One of the two fire extinguishers, specifically the fire extinguisher by the rear exit door did not indicate an inspection date.
The word "Loaner" was written on the back of the inspection tag.
The Executive Director confirmed the findings.
|
Plan of Correction
It is the responsibility of the Executive Director to ensure fire extinguishers are inspected and approved annually and that any loaner extinguishers are marded with month hole punched date on label.
Loaner fire extinguisher was loaned and replaced by Montgomery-Delaware Fire Extinguisher Company. New extinguisher dated November 2012. Facility is in compliance. |
Observations
Based on a review of client records the facility failed to document a psychosocial evaluation that was evaluative.
The findings include:
On January 5, 2012, seven client records were reviewed for documentation of a psychosocial evaluation.
The facility failed to document an evaluative psychosocial evaluation in four of seven client records reviewed, specifically # 1, 2, 4, and 5.
Client # 1 was admitted to the program on 10/25/11.
The psychosocial evaluation was documented on 10/25/11.
However, the facility failed to document a psychosocial evaluation that was evaluative.
The clinician failed to provide an assessment regarding how the client's problems, assets/strengths, support systems, coping mechanisms and negative factors would affect the client's treatment as the evaluation stated " client reports" and "client identifies."
Client # 2 was admitted to the program on 9/8/11.
The psychosocial evaluation was documented on 9/12/11.
However, the facility failed to document a psychosocial evaluation that was evaluative.
The clinician failed to provide an assessment regarding how the client's problems, assets/strengths, support systems, coping mechanisms and negative factors would affect the client's treatment as the evaluation stated "client reports" and "client identifies."
Client # 4 was admitted to the program on 9/9/11.
The psychosocial evaluation was documented on 9/13/11.
However, the facility failed to document a psychosocial evaluation that was evaluative.
The clinician failed to provide an assessment regarding how the client's problems, assets/strengths, support systems, coping mechanisms and negative factors would affect the client's treatment as the evaluation stated "client reports" and "client identifies."
Client # 5 was admitted to the program on 10/18/11.
The psychosocial evaluation was documented on 10/26/11.
However, the facility failed to document a psychosocial evaluation that was evaluative.
The clinician failed to provide an assessment regarding how the client's problems, assets/strengths, support systems, coping mechanisms and negative factors would affect the client's treatment as the evaluation stated "client reports" and "client identifies."
The Executive Director did not dispute the findings.
|
Plan of Correction
It is the responsibility of the counselor completing psycho-social to document assessment of client in client record.
The clinical team will be trained by 1/30/12 at Monday staff meetings on proper assessment documentation.
It is the responsibility of the clinical supervisor to ensure that assessments are written properly in each client record before signing off on paperwork.
It is the responsibility of program Director to ensure overall compliance. |