INITIAL COMMENTS
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This report identifies the findings of an on-site complaint investigation conducted on September 11, 2008 by staff of the Division of Drug and Alcohol Licensure. The following deficiencies were identified during the investigation and a plan of correction is due on October 14, 2008.
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Plan of Correction
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709.26(a)(7) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(7) Rules of conduct.
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Observations
Based on a complaint investigation conducted on September 11, 2008, facility staff failed to act in accordance with the Rules of Conduct listed in the facility personnel policies and procedures, specifically rules # 14 and 20.
Findings:
Rule of Conduct # 14 states that "All employees shall respect and enforce the "Patient Rights" as documented in this manual." and Rule of Conduct # 20 which states that "At all times all employees must uphold and enforce the confidentiality of all residents and resident records. Staff and client interviews revealed that staff members violated rule of conduct #14 and #20 by bringing a family member to work on various occasions. Three staff members and one client confirmed during an interview with the licensing specialist that a staff member brought a child to work with her. Another staff member confirmed that a staff member had his wife at the facility with him on at least one occasion. Residents were given work therapy assignments that involved typing letters and filing paperwork which compromises the confidentiality of other residents in treatment.
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Plan of Correction
All staff are required to uphold and enforce the confidentiality of all residents and records. It shall be policy of Harwood that No employee shall have visitors in the facility.
It shall also be the policy of Harwood House that residents will not be allowed to use any computer on the site. It shall be Harwood policy that only clinical staff will file confidential paperwork.
It shall be the responsibility of all staff to maintain confidentiality of all residents and records. It shall be the responsibility of the clinical supervisor to monitor the counselors and program workers for compliance with this standard. It shall be the responsibility of the Executive Director for overall compliance.
Time Frame: All staff will be retrained on these policies by November 1, 2008 |
709.26(a)(12) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(12) Employe grievances.
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Observations
Based on a complaint investigation conducted on September 11, 2008, the facility failed to document a staff members verbal grievance as required by facility policy and procedure.
Findings:
Based on a phone conversation with facility staff on September 17, 2008, the facility failed to document in writing an employee grievance that was taken verbally. According to facility policy/procedure, employee grievances are to be filed with the Executive Director first, who will have five days to respond. If a satisfactory resolution has not been reached, the employee may file with the personnel committee within three days. The personnel committee will have five days to respond. If a satisfactory resolution has not been reached, the employee may file with the governing body within three days. The governing body then has five days to make a final decision. According to the phone conversation, a counselor made a verbal grievance known, but it was not put in writing according to facility policy.
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Plan of Correction
All staff are responsible for following policy and procedure regarding filing a grievance. The Board of Directors is responsible for documenting any employee grievance made to them.
Time Frame for compliance: All staff will be trained in the procedure for properly filing a grievance by November 1,2008.
The board has selected a board member who is responsible for maintaining a copy of all employee grievances and make available fo state entities. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records during a complaint investigation conducted on September 11, 2008, the facility failed to obtain an informed and voluntary consent from the client for disclosure of treatment services.
Findings:
Based on staff and client interviews, it was determined that client confidentiality was breached when a staff member brought a family member to work with them with out obtaining consent from the clients of the residential program. Three staff members and one client confirmed this in an interview with the licensing specialist.
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Plan of Correction
It is the responsibility of all staff to uphold client confidentiality. It shall be the policy that there will not be any visitors in the faclity with out documented consent by from the clients. It shall be the overall responsibility of the Executive Director to uphold confidentiality in the facility.
Time Frame: All staff will be trained on the new Policy by 11/15/2008. The trainings will be documented in the employee chart. |