Observations
Based on applicable patient records reviewed, the facility failed to have an annual evaluation of each patient ' s status that was completed by the patient ' s counselor and was reviewed, dated, and signed by the medical director in three of three records. The annual evaluation period shall start on the date of the patient ' s admission to a narcotic treatment program.Patient #5 was admitted to on February 10, 2022 and was still active at the time of the inspection. The annual evaluation was completed on February 7, 2025, however this was not signed by the medical director at the time of the inspection.Patient #6 was admitted to on August 10, 2018 and was still active at the time of the inspection. The annual evaluation was completed on August 7, 2024, however this was not signed by the medical director at the time of the inspection.Patient #7 was admitted to on October 19, 2020 and was still active at the time of the inspection. The annual evaluation was to be completed by October 19, 2024, however this was not completed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The director re-educated the clinical and the medical team on the policy concerning annual evaluations, 03/28/2025. The annual evaluation period shall start on the date of the patient's admission to a narcotic treatment program.The annual evaluation will be completed by the clinical team, and annual evaluation will be reviewed, dated, and signed by the medical director. The treatment team will keep track of due dates for annual evaluations using a spreadsheet and SAMMs reporting, and SAMMs program holds/reminders; commencing 04/04/2025. |