Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in one of two applicable client records reviewed.
The facility policy and procedure manual stated the emergency contact will be notified after a client is discharged from the facility against medical advice.
Client #5 was admitted on April 21, 2025 and was discharged against medical advice on April 25, 2025. There was no documentation in the record indicating the emergency contact was notified the client was discharged against medical advice at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will provide and review the Emergency Contact Policy to respective staff during supervision and document accordingly.
a). Responsible Party:
Clinical Supervisor, Behavioral Specialists, and support staff (Community Recovery Specialist/Mental Health Technician, and Addiction Recovery Assistants)
b). Completion Date: 9/30/2025
Staff will document in the client's record attempt to notify emergency contact when a client leaves the facility against medical advice.
a). Responsible Party:
Clinical Supervisor, Behavioral Specialists, and support staff (Community Recovery Specialist/Mental Health Technician, and Addiction Recovery Assistants)
b). Completion Date: 9/30/2025
Clinical Supervisor will conduct focus review of 90% or 5 charts of clients who leave the facility against medical advice during a 2-month period to ensure that the client emergency contact was notified.
a). Responsible Party:
Clinical Supervisor,
b). Completion Date: 11/30/2025
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