Observations
Based on a review of a client record and the Universal Rounding Policy for Withdrawal Management and Residential Programming, the facility failed to follow its written procedures for the management of treatment and rehabilitation services for clients.
Per the Universal Rounding Policy for Withdrawal Management and Residential Programming, rounds must be face-to-face and confirm client location. For sleeping clients, staff must observe respirations. Rounding documentation must be completed using universal forms, initialed at the time of observation, signed at the end of shift, and submitted to the appropriate supervisor. If rounds cannot be completed, staff must notify the shift supervisor immediately. Residential Rounding is to be done every 60 minutes unless the client is already confirmed to be in a clinical or medical activity.
Client # 1 was admitted on April 9, 2026, and discharged on April 20, 2026. Documentation of residential rounding was missing from the client record for April 20, 2026.
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Plan of Correction
BHT staff will conduct rounding every hour per shift. BHT Supervisor will review rounding sheets daily to ensure completion and accuracy. The BHT Manager will conduct random audits monthly to ensure completion and accuracy. Any ongoing issues with be addressed in staff supervision. This process will be re-reviewed with BHT staff during the monthly staff meeting on 7/10/26. |