Observations
Based on Licensing Specialist observations and interviews with facility staff, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room and/or counseling area.
The findings include:
A physical plant inspection was conducted on October 28, 2014 from approximately 11:15 A.M. to 12:30 P.M. During the physical plant inspection, the Licensing Specialist heard group counseling sessions outside of Conference Room # 342 on the 3rd floor. Based on interviews with facility staff, group counseling sessions are also held in the 1st floor Detox lounge, the north 2nd floor Rehab lounge, the south 2nd floor Rehab lounge, the 3rd floor Rehab lounge, the 5th floor Rehab lounge, and the outside courtyard. It was reported that the areas mentioned do not provide privacy and that group counseling sessions can be seen and/or heard outside of the counseling areas.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will be utilizing additional rooms for group room space in order to stop the use of the lounges for groups. The facility will no longer allow the outdoor area to be utilized for group therapy sessions. The facility will provide a sound machine for group room #342 to prevent people outside the room from hearing the contents of the group session. The clinical director will visit all group rooms and ensure that confidentiality is being maintained. The program director will ensure that all groups are held in a confidential space and that sound machines are purchased for all areas where it is deemed necessary. |