Observations
Based on a review of client records, the facility failed to appropriately document a dated signature of the witness on release of information forms in six of seven client records reviewed.
Client #1 was admitted on September 8, 2020 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on September 8, 2020. The dated signature of the witness was completed on September 12, 2020.
Client #2 was admitted on October 19, 2020 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on October 13, 2020. The dated signature of the witness was completed on December 3, 2020. Additionally, a release of information form to an emergency contact was signed and dated by the client on October 15, 2020. The dated signature of the witness was completed on October 26, 2020.
Client #3 was admitted on December 22, 2020 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on December 22, 2020. The dated signature of the witness was completed on February 23, 2021.
Client #4 was admitted on September 9, 2020 and discharged on January 27, 2021. A release of information form to an emergency contact was signed and dated by the client on September 8, 2020. The dated signature of the witness was completed on September 19, 2020. Additionally, a release of information form to the funding source was signed and dated by the client on September 8, 2020. The dated signature of the witness was completed on February 24, 2021.
Client #6 was admitted on January 25, 2021 and discharged on April 8, 2021. A release of information form to an emergency contact was signed and dated by the client on January 25, 2021. The dated signature of the witness was completed on January 26, 2021. Additionally, another release of information form to an emergency contact was signed and dated by the client on January 25, 2021. The dated signature of the witness was completed on January 26, 2021. Additionally, a release of information form to the funding source was signed and dated by the client on January 25, 2021. The dated signature of the witness was completed on January 26, 2021.
Client #7 was admitted on September 15, 2020 and discharged November 16, 2020. A release of information form to the funding source was signed and dated by the client on September 15, 2020. The dated signature of the witness was completed on September 19, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/22/21 program director updated "Staff Signature" line to "Witness Signature" on all release of information forms. System was also configured to require a witness signature in order for forms to be electronically submitted by the client. Program director reviewed release of information policies with all staff members. Clients 1, 2, & 3 will sign new release forms during their next individual session or by 5/7/2021 to be witnessed by staff or another party of the client's choosing. Staff will ensure appropriate documentation of a dated client and witness signature. Program director will complete quarterly chart reviews to ensure documentation is appropriately completed. |
Observations
Based on a review of the August 2020 through March 2021 fire drill log, the facility failed to conduct fire drills at different times of the day. Each of the facility's fire drills were conducted between 12pm-3pm and none were conducted during the facility's morning and evening hours.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program director reviewed fire safety regulations with all staff members on 4/22/21. Program director will ensure monthly fire drills are conducted at different days, shifts, and times (including mornings, afternoons and evenings). |