Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client in one out of one applicable record reviewed.
Client #7 was admitted on August 16, 2024 and was administratively discharged on September 6, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Discharge Checklist utilized by Program Counselors and Program Therapists to verify and garner approval from a supervisor to finalize the discharge process has been updated to include specific information regarding the "Involuntary Termination Letter" and when it must be completed by the clinician as opposed to by supervisory leadership as the missing letter identified during the review of client records was a case of confusion regarding the ultimately responsible party.
The Compliance Officer, in collaboration with the Homestead Site Director, conducted retraining sessions for Homestead Clinical Leadership and Program Counselors and Program Therapists during a staff meeting on 10/1/2024. The retraining emphasized the responsibility of clinical team members vs. supervisory leadership, the update to the Discharge Checklist, and reiterated timeframe expectations of the completion of Discharge Checklists. Particular attention was given to the need to complete the Involuntary Termination Letter in all cases, regardless of whether the client is physically present for the discharge conversation or not.
The Compliance Officer has established an additional monthly auditing process, which began on 10/7/2024, to compare the presence of "Involuntary Termination Letters" to Discharge Types to verify that this update was successful. This additional monitoring will continue monthly for six months or until 100% accuracy has been maintained for three months, whichever milestone is achieved first. Further retraining and process improvements will be conducted in the case that errors continue.
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