Observations
Based on a physical plant inpsection the facility failed to limit smoking to designated smoking areas.
A physical plant inspection was conducted on October 15, 2014 at approximately 2pm. During the inspection of the inpatient male wing ashes and cigarettes were observed in the shower stall of the mens bathroom. Facility policy prohibits smoking inside the building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure that smoking will be limited to the designated smoking areas, the following process will be inforced: (1)signs with the verbiage "NO SMOKING" will be posted inside all bathrooms and on wall entrance areas. (2)On a daily basis, in community meetings of each floor, the staff (counselors) will make daily policy and proceedural announcements that smoking is not permitted inside the building. Directors will provide client handbooks that announce the facility is a non smoking facility except for outside designated areas.(3) staff (Aids, counselors, supervisors and Directors)will do 15 minute checks for bathroom compliance to ensure the no smoking policy is being respected, as well as monitor the area by posting staff within 5-10 feet of the entrance area of the bathroom(s)on an as-needed basis to prevent suspected violations from occuring. |
Observations
Based on the review of client records, the facility failed to provide a complete client record on each individual in four of ten client records.
The findings include:
Ten client records were reviewed on October 14-16, 2014. The facility did not provide a complete client record for records #2,3,5 and 10.
Client #2 was admitted to treatment on August 18, 2014 and was still active in treatment as of the date of the inspection. Client #2 had a individual treatment plan that appeared to be altered to reflect the date completed. The client signed and dated the treatment plan September 30, 2014. That date was crossed out by the counselor and dated August 25, 2014.
Client #3 was admitted to treatment on August 4, 2014 and was still active on the date of the inspection. Client #3 did not have documentation of an individual treatment plan. The only treatment plan provided in the record was the preliminary treatment plan.
Client #5 was admitted to treatment on May 9, 2014 and was discharged on June 12, 2014. Client #5 did not have documentation of a follow up contact. Per facility policy a follow up contact was due by July 17, 2014.
Client #10 was admitted to treatment on May 23, 2014, and was discharged on June 5, 2014. Client #10 did not have documentation of a follow up contact. Per facility policy a follow up contact was due by July 5, 2014
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
To ensure that treatment plans are documented correctly in the clinical file, a tracking form will be created by the Clinical Supervisor of the inpatient program, identifying upcoming due dates for various timely documents, including treatment plans. This tracking form will be reviwed by the program director daily to assure that each date is the date specified as signed on site.
To ensure that follow-up information is documented in the client record 30 days after discharge, the Clinical Supervisor will review all discharges on a weekly basis via a discharge log. Follow up information specifying the date and method of contact (phone, mail, other), will then be documented by the Clinical Supervisor. A copy of this follow up will be placed in the client record.
Training on the tracking form and the follow up log will be facilitated by the Program Director and the Clinical Supervisor to reinforce standard 709.53 (a), by January 7, 2015.
The tracking form and the follow up log will be reviewed and monitored during monthly Continous Quality Imporvement (CQI) meetings to ensure compliance, completion and time lines.
Persons Responsible: Program Director, Clinical Supervisor. |