Observations
Based on observations on July 17, 2014, 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 July 17, 2014. It was observed during the inspection from approximately 10:15 A.M. to 10:32 A.M., that the facility had one fire extinguisher on the first floor and one fire extinguisher on the second floor that had not been inspected and approved by the local fire department or fire extinguisher company since March 2013.
The findings were confirmed during an interview with the safety officer on July 17, 2014 at approximately 10:35 A.M.
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Plan of Correction
1. Fire Marshall will order new extingusihers within the next 2 weeks.
2. Facility engineers will conduct monthly visual inspection of all fire extinguishers in the building.
3. A outside vendor will conduct annual inspections of all fire extinguishers.
4) Facility engineers will be responsible for making sure that the one fire extinguisher on the first floor and the one fire extinguisher on the second floor are inspected and approved by the local fire department.
5) Facility engineers will provide oversight and monitoring compliance of conducting monthly visual inspection of all fire extinguishers in the building.
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Observations
Based on a review of client records, the facility failed to document treatment and rehabilitation plan updates at least every 60 days in six of fifteen client records reviewed.
The findings include:
Fifteen client records requiring documentation of treatment and rehabilitation plan updates were reviewed from July 16, 2014 to July 17, 2014. The facility failed to document a treatment and rehabilitation update at least every 60 days in client records # 2, 3, 7, 9, 12 and 16.
Client # 2 was admitted January 8, 2014. A treatment plan update was completed March 19, 2014 and another treatment plan update was due May 18, 2014. However, the additional treatment plan update was not completed until June 30, 2014.
Client # 3 was admitted December 19, 2013. A treatment plan update was completed April 28, 2014 and another treatment plan update was due June 27, 2014. However, the additional treatment plan update was not completed until June 30, 2014.
Client # 7 was admitted January 21, 2014. Treatment plan updates were completed February 12, 2014 and March 24, 2014. Another treatment plan update was due June 23, 2014 but client record # 7 did not include documentation of the treatment plan update as of July 17, 2014.
Client # 9 was admitted February 28, 2014. The individual treatment and rehabilitation plan was completed March 27, 2014. The treatment plan update was due May 26, 2014 but client record # 9 did not include documentation of a treatment plan update as of July 17, 2014.
Client # 12 was admitted January 21, 2014 and discharged May 27, 2014. A treatment plan update was completed February 19, 2014 and another treatment plan update was due April 27, 2014. However, client record # 12 did not include documentation of the additional treatment plan update as of July 17, 2014.
Client # 16 was admitted December 3, 2013 and discharged June 3, 2014. The individual treatment and rehabilitation plan was completed January 6, 2014. The treatment plan update was due March 6, 2014 but client record # 16 did not include documentation of a treatment plan update as of July 17, 2014.
The findings were confirmed during an interview with the facility director on July 17, 2014 at approximately 3:30 P.M.
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Plan of Correction
1. Clinical supervisors will continue to monitor counselors ability to develop and complete treatment plans as stated in Policy : 911.92
2) Each clinical supervisor will review
(24) charts a month to assess
counselors ability to maintain
quantity and quality of work and
follow Policy: 911.92
3) Clinical supervisor will provide individual supervision for counselors of participant records # 2,3,7,9,12 and 16 for quality of work and quantity of work , report and recordkeeping by 8/15/2014.
4) Clinical supervisors will in-serviced with each staff by 8/15/2014.
5) Clinical supervisors will
perform a in-sevice on treatment
plan development in team
meeting on 8/15/2014
6) Clinical supervisors will provide oversight and monitoring of compliance to documentation of treatment and rehabilitation plan updates at least every 60 days standard.
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