Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguisher to the left of the front desk has not been inspected since November 2022.
This findings was reviewed with facility staff during the licensing process.
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Plan of Correction
Monthly front office staff will do a Fire Drill & Checks Report sheet. On this sheet an additional line to review all fire extinguishers within the facility to ensure the appropriate tag is on them for current inspections. This report will be sent monthly to the Safety Chairperson to ensure all dates are correct and that the fire extinguishers are current with their inspection. Outpatient's fire drills workflow has been updated to include this change to the report. Supervisors will complete education on updates to this report and workflow with all Outpatient staff by 10/4/24. |
Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven client records reviewed.
Client #1 was admitted on February 19, 2024 and was still active at the time of the inspection. A treatment plan update was completed on March 4, 2024 and the next update was due no later than May 4, 2024; however, there was no update documented in the record until June 3, 2024.
Client #3 was admitted on March 22, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 8, 2024 and the next update was due no later than July 8, 2024; however, there was no update documented in the record at the time of the inspection.
Client #4 was admitted on March 25, 2024 and was still active at the time of the inspection. A treatment plan update was completed on April 15, 2024 and the next update was due no later than June 15, 2024; however, there was no update documented in the record until June 21, 2024.
Client #6 was admitted on December 18, 2023 and was discharged on May 23, 2024. A treatment plan update was completed on January 24, 2024 and the next update was due no later than March 24, 2024; however, there was no update documented in the record until April 3, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisors will complete re-education with staff on completing treatment plans and treatment plan updates workflow as well as monitoring treatment plans workflow by 10/4/24. Updates to the Monitoring Treatment Plans workflow have been made to reflect the following changes in process listed below. -Clinicians dashboards will be pulled weekly from electronic health record by front office and emailed to clinician and supervisor weekly to review any upcoming treatment plans. This document will be an editable working document. Clinicians will be responsible to update on the comments section date of completion. Supervisors will review this daily and meet individually with any clinicians that are failing to get the plans completed prior to date on the dashboard. Front office will review weekly differences in dashboards to ensure treatment plans have not expired. |