Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
The findings include:
A physical plant inspection was conducted with the facility maintenance chief and the administrative assistant on October 26, 2015 at approximately 9:00 am. The male client bathroom in the second floor apartment on the 438 side of the facility was observed to have black mold growing on the heater vent, which was located on the ceiling.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All bathrooms in both buildings , 438-440, will be inspected prior tp 11/13/2015, the administrative assistant and maintenance personnel will install new ventilation units in all bathrooms, which will be installed no later than 12/22/2015. for the short term, prevention of mold will occur as we will require all clients to open the bathroom window, with shades drawn, during all times using the shower. Overall supervision of this project will be done by the Executive Director. |
Observations
Based on a review of client records, the facility failed to assure that counseling services were provided to the clients according to their individual treatment and rehabilitation plans in ten of ten client records.
The findings include:
Ten client records, all of which required that counseling services were provided according to the treatment plan, were reviewed on October 26, 2015. The facility did not accurately document the reflection of counseling services provided according to the treatment plan in client record #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.
Client #1 was admitted into treatment on September 8, 2015 and was still an active client at the time of the inspection. Client #1's treatment plan, dated 09/09/2015, stated that the client was to receive 1 group therapy session per day while in treatment. As of the date of the inspection, there were only 14 group sessions documented in the client record for the months of September 2015 and October 2015.
Client #2 was admitted into treatment on August 18, 2015 and was still an active client at the time of the inspection. Client #2's treatment plan, dated 08/21/2015, stated that the client was to receive 2 group therapy sessions per day while in treatment. As of the date of the inspection, there were only 35 group sessions documented in the client record for the months of August 2015, September 2015, and October 2015.
Client #3 was admitted into treatment on July 16, 2015 and was still an active client at the time of the inspection. Client #3's treatment plan, dated 07/17/2015, stated that the client was to receive 1 group therapy session per day while in treatment. As of the date of the inspection, there were only 51 group sessions documented in the client record for the months of July 2015, August 2015, September 2015, and October 2015.
Client #4 was admitted into treatment on August 10, 2015 and was still an active client at the time of the inspection. Client #4's treatment plan, dated 08/11/2015, stated that the client was to receive 1 group therapy session per day while in treatment. As of the date of the inspection, there were only 25 group sessions documented in the client record for the months of August 2015, September 2015, and October 2015.
Client #5 was admitted into treatment on October 17, 2014 and was discharged on November 30, 2014. Client #5's treatment plan, dated 10/24/2014, stated that the client was to receive 2 group therapy sessions per day while in treatment. As of the date of the inspection, there were only 15 group sessions documented in the client record for the months of October 2014 and November 2014.
Client #6 was admitted into treatment on January 26, 2015 and was discharged on April 24, 2015. Client #6's treatment plan, dated 01/27/2015, stated that the client was to receive 2 group therapy sessions per day while in treatment. As of the date of the inspection, there were only 13 group sessions documented in the client record for the months of January 2015, February 2015, March 2015, and April 2015.
Client #7 was admitted into treatment on November 3, 2014 and was discharged on January 22, 2015. Client #7's treatment plan, dated 11/03/2014, stated that the client was to receive 1 group therapy session per day while in treatment. As of the date of the inspection, there were only 25 group sessions documented in the client record for the months of November 2014, December 2014, and January 2015.
Client #8 was admitted into treatment on August 6, 2015 and was discharged on September 30, 2015. Client #8's treatment plan, dated 08/10/2015, stated that the client was to receive 2 group therapy sessions per day while in treatment. As of the date of the inspection, there were only 8 group sessions documented in the client record for the months of August 2015 and September 2015.
Client #9 was admitted into treatment on September 10, 2014 and was discharged on November 25, 2014. Client #9's treatment plan, dated 09/17/2014, stated that the client was to receive 2 group therapy sessions per day while in treatment. As of the date of the inspection, there were only 13 group sessions documented in the client record for the months of September 2014, October 2014, and November 2015.
Client #10 was admitted into treatment on May 27, 2015 and was discharged on August 26, 2015. Client #10's treatment plan, dated 05/28/2015, stated that the client was to receive 2 group therapy sessions per day while in treatment. As of the date of the inspection, there were only 43 group sessions documented in the client record for the months of May 2015, June 2015, July 2015, and August 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each counselor will be responsible for ensuring that their clients treatment plan specifically articulate the type and frequency of their group and individual sessions.Based on the treatment plan, the counselor will be responsible in ensuring that the client receives the services that are reflected in the treatment plan.Supervision of the counselors by the executive director and random chart reviews done by the counselors/executive director will be conducted on a monthly basis to ensure compliance. The date this deficiency will be in compliance is 11/13/2015. |
Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes discharge summaries and follow-up information in three of ten client records reviewed.
The findings include:
Ten client records requiring a complete client record on an individual were reviewed on October 26, 2015. The facility did not provide a complete client record for client #s 5, 7, and 9.
Client #5 was admitted into treatment on October 17, 2014 and was discharged on November 30, 2014. The facility failed to include documentation of a discharge summary, as well as any follow-up information after discharge, as of the date of the inspection.
Client #7 was admitted into treatment on November 3, 2014 and was discharged on January 22, 2015. The facility failed to include documentation of any follow-up information after discharge as of the date of the inspection.
Client #9 was admitted into treatment on September 10, 2014 and was discharged on November 25, 2014. The facility failed to include documentation of a discharge summary, as well as any follow-up information after discharge, as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For the clients identified in the deficiency, the respective counselors will review the records and complete discharge summary, if applicable, and follow ups will be conducted, if applicable to ensure that those client records are in compliance. To ensure that this does not occur again in the future, all counselors will be responsible for ensuring that, upon client discharge, all discharge summaries and follow ups will be conducted and documented in the client chart. Random chart reviews will be conducted by the counselor and executive director during supervision meetings to further ensure compliance. The deficiency will be corrected by 11/13/2015 |