Observations
Based on a review of staff records conducted on February 7, 2019, the facility failed to ensure that a staff member received the required communicable disease trainings within the specified time frame.
Staff #2 was hired as a counselor on May 16, 2016; the HIV/AIDS and TB/STD trainings were due to be completed by May 16, 2017 but were not documented at the time of the licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
This was a repeat citation from the January 16, 2018 inspection.
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Plan of Correction
Staff member registered for TB/STD on March 5, 2019 and HIV on March 27, 2019. Going forward it is the responsibility of the director to complete monthly employee file reviews of training calendar and ensure that the staff sign up and provide proof of training registration. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
During an inspection of seven client records on February 7, 2019, the facility failed to ensure that they had written policies and procedures to address all client rights.
Client #1 had been admitted on September 27, 2018 and was still active at the time of the inspection. Client #1 had not been informed that the project may not discriminate on the basis of age, creed, ethnicity, national origin, marital status or sexual orientation.
Client #2 had been admitted on September 5, 2018 and was discharged on December 5, 2018. Client #2 had not been informed that the project may not discriminate on the basis of age, creed, ethnicity, national origin, marital status or sexual orientation.
Client #3 had been admitted on June 21, 2018 and was still active at the time of the inspection. Client #3 had not been informed that the project may not discriminate on the basis of age, creed, ethnicity, national origin, marital status or sexual orientation.
Client #4 had been admitted on June 11, 2018 and was discharged on January 16, 2019. Client #4 had not been informed that the project may not discriminate on the basis of age, creed, ethnicity, national origin, marital status or sexual orientation.
Client #5 had been admitted on May 14, 2018 and was still active at the time of the inspection. Client #5 had not been informed that the project may not discriminate on the basis of age, creed, ethnicity, national origin, marital status or sexual orientation.
Client #6 had been admitted on May 7, 2018 and was still active at the time of the inspection. Client #6 had not been informed that the project may not discriminate on the basis of age, creed, ethnicity, national origin, marital status or sexual orientation.
Client #7 had been admitted on September 27, 2018 and was discharged on January 16, 2019. Client #7 had not been informed that the project may not discriminate on the basis of age, creed, ethnicity, national origin, marital status or sexual orientation.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Policy language updated by the director on day of licensing visit, 2/7/19. This will be the responsibility of the director who will review licensing updates monthly beginning immediately to ensure compliance.
All clients still in treatment will sign an updated policy at their next appointment |