Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one of seven records reviewed.Client #3 was admitted on April 30, 2025 and discharged on August 1, 2025. The informed and voluntary consent form to a significant other was signed and dated April 30, 2025; however, there was no purpose of disclosure indicated on form. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to obtain an informed an voluntary consent from the client for disclosure of information contained in the client record that included the purpose of disclosure.
To correct this deficiency, a training took place between the Clinical Supervisor and the Intake Coordinator addressing the need to be specific in the event that someone is asking for information and what specific information the client is wishing to disclose to the individual. We are not to disclose any information or have the client sign the consent form unless we are specificaly identifying the information to be disclosed.
To prevent re-occurrance of this deficiency, the intake coordinator and the Clinical Supervisor will review the client files and inspect the consent to release information forms bi-weekly during staff meetings to be sure they are identifying specific information to be disclosed. |
Observations
Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered in four out of five applicable client records reviewed.Client #2 was admitted on May 13, 2025 and discharged on July 30, 2025. Client was prescribed Propranolol tab 20mg 2x daily. There is no documentation for the second daily dose of medication being administered or the reason not administered on July 4, 2025, July 12, 2025, July 16, 2025, and July 25, 2025. Client was prescribed Buprenorphine/Naloxone Sublingual 8-2mg two tabs daily. There was no documentation for the medication being administered or the reason not administered on July 1, 2025, and July 20, 2025.Client #3 was admitted on April 30, 2025 and discharged on August 1, 2025. Client was prescribed Duloxetine 1x daily. There is no documentation for the medication being administered or the reason not administered on July 1, 2025, July 8, 2025, and July 9, 2025.Client #6 was admitted on August 21, 2025 and was still active at the time of licensing process. Client was prescribed Atomoxetine Ccp 60mg 1x daily. There is no documentation for the medication being administered or the reason not administered on August 29, 2025.Client #7 was admitted on August 1, 2025 and was still active at the time of licensing process. Client was prescribed Oxcarbazepine tab 300 mg 2x daily. There was no documentation for the first dose of medication being administered or the reason not administered on September 28, 2025. Client was prescribed Olanzapine 5mg 1x daily. There was no documentation for the medication being administered or the reason not administered on September 28, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document the administration or the reason a medication was not administered in the MAR.
To correct this deficiency, the Clinical Supervisor is holding weekly staff meetings expressing the need to document all meds that are administered or not administered in the MAR as it is occurring. If the client takes his meds or does not take his meds or does not show, this has to be documented.
To prevent re-occurrance of this deficiency, daily monitoring of the MAR will be performed by all Community Managers, Counselors and the Clinical Supervisor. Along with weekly staff meetings where the MAR will reviewed. |