Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in three of three applicable records.
Client #5 was admitted to the inpatient level of care on August 15, 2024 and was discharged August 16, 2024.
Client #11 was admitted to the outpatient level of care on November 21, 2024 and was discharged January 2, 2025.
Client #12 was admitted to the outpatient level of care on October 23, 2024 and was discharged November 20, 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 04/01/2025, staff will be provided documented training on the need to complete Discharge Notification forms when a client is involuntarily discharged from treatment. To ensure ongoing compliance with this standard, a "Discharge checklist" was created to utilize when completing discharge processes. The checklist includes "Notice of Termination" for all clients whoa re involuntarily discharged from treatment. The Executive Director, in coordination with the QA team, will review charts monthly to ensure ongoing compliance with the above referenced standard. |