Observations
Based on a physical plant inspection conducted at approximately 10:00 AM, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents as evidenced by the following:
1) The trash dumpster located at the end of the driveway was overflowing with trash.
2) Next to the dumpster were piles of trash that were not in a trash dumpster or covered.
These findings were reviewed with facilty staff during the licensing process.
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Plan of Correction
On August 2, 2016 Office Manager called trash company and effective August 8, 2016 trash company will begin a second route (Monday and Thursday) to facility for trash collection. This will ensure that all trash, rubbish and garbage is removed from physical plant in timely fashion. This extra pick up date will make certain that trash is not overflowing from trash receptacle. Clinical Supervisor will monitor weekly to ensure trash is being collected twice weekly. |
Observations
The facility failed to obtain an informed and voluntary consent to release in nine of ten client records reviewed during the course of the annual licensing inspection on July 20, 2016.
Client #1 was admitted to treatment on November 30, 2015 and was still an active client at the time of inspection. Two consent forms dated November 30, 2015, the facility failed to document the purpose of disclosure. In addition, a consent from dated November 30, 2015, the facility failed to document the specific information to be released.
Client #2 was admitted to treatment on December 3, 2015 and was still an active client at the time of inspection. Two consent forms dated December 3, 2015, the facility failed to document the purpose of disclosure. In addition, a consent from dated December 3, 2015, the facility failed to document the specific information to be released.
Client #3 was was admitted to treatment on January 25, 2016 and was still an active client at the time of inspection. Two consent forms dated January 25, 2016, the facility failed to document the purpose of disclosure. In addition, a consent from dated January 25, 2016, the facility failed to document the specific information to be released.
Client #4 was was admitted to treatment on April 30, 2016 and was still an active client at the time of inspection. Two consent forms dated May 2, 2016, the facility failed to document the purpose of disclosure. In addition, a consent from dated May 2, 2016, the facility failed to document the specific information to be released.
Client #5 was admitted to treatment on May 10, 2016 and was still an active client at the time of inspection. Two consent forms dated May 10, 2016, the facility failed to document the purpose of disclosure. In addition, a consent from dated May 10, 2016, the facility failed to document the specific information to be released.
Client #6 was admitted to treatment on February 5, 2016 and discharged May 11, 2016. Two consent forms dated February 5, 2016, the facility failed to document the purpose of disclosure. In addition, a consent form dated February 5, 2016, the facility failed to document the specific information to be released.
Client #7 was admitted to treatment on November 23, 2015 and discharged May 5, 2016. One consent form dated October 16, 2015, the facility failed to document the purpose of disclosure.
Client #9 was admitted to treatment on March 10, 2016 and discharged June 26, 2016. Two consent forms dated March 10, 2016, the facility failed to document the purpose of disclosure. In addition, a consent form dated March 10, 2016, the facility failed to document the specific information to be released.
Client #10 was admitted to treatment on January 21, 2016 and discharged May 2, 2016. Two consent forms dated January 21, 2016, the facility failed to document the purpose of disclosure. In addition, a consent form dated January 21, 2016, the facility failed to document the specific information to be released.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By August 25, 2016 the Program Director will train all staff on proper procedures when completing informed voluntary consent forms. During training, Program Director will cover in detail all sections including writing out what outside agency/person consent is for, specific information that consent will cover and checking off appropriate boxes when identifying the purpose of the disclosure. Lastly the training will cover the appropriate length of each consent (not exceeding 1 year) and having client's and witness' signature on each consent.
Charts will be review monthly by both Clinical Supervisor and Program Director to ensure that consents are being completed correctly and in their entirety.
By 8/25/ 2016 Program Director will meet with clients #1,2,3,4,5 to complete consents in their entirety. Program Director will document the purpose of the disclosures and identify and check appropriate box for the specific information to be released on consents.
Program Director will also review all open charts to ensure that each disclosure consents are completed correctly and in their entirety.
In the event that any consent is not completed correctly, Program Director will meet with the respective client to complete consent and then meet with staff member to go over consent and discuss reason(s) consent was not correct.
Clients #6, 7,9,10 are all discharged charts.
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Observations
The facility's unusual incident report log was reviewed on July 20, 2016. The facility failed to report to the Department events that required the presence of police or ambulance personnel onsite. These documented events occurred on 2/29/2016, 2/25/2016, 3/14/2016, 3/7/2016, 5/18/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By August 25, 2016 Program Director will train all staff on procedures for reporting unusual incidents that require police, ambulance or fire personnel presences onsite. Staff will be taught regulations on informing DDAP of such incidents and provided the fax number to ensure that incidents are faxed to DDAP within 3 days. The Program Director will review all incident reports and monitor on-going compliance through supervision and monthly staff meeting. |