Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in four of four client records.
The findings include:
Ten client records were reviewed on May 27-28, 2015. Six of the client records reviewed were that of discharged clients. Four of the discharged clients were involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client records, #2, 3, 5, and 6.
Client # 2 was admitted into treatment on December 30, 2014 and was involuntarily terminated from the project on March 3, 2015. There was no documentation of a written notification provided to the client as of the date of the licensing inspection.
Client # 3 was admitted into treatment on March 26, 2015 and was involuntarily terminated from the project on May 5, 2015. There was no documentation of a written notification provided to the client as of the date of the licensing inspection.
Client # 5 was admitted into treatment on January 8, 2015 and was involuntarily terminated from the project on April 24, 2015. There was no documentation of a written notification provided to the client as of the date of the licensing inspection.
Client # 6 was admitted into treatment on July 14, 2014 and was involuntarily terminated from the project on March 12, 2015. There was no documentation of a written notification provided to the client as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Per DDAP policy 709.33 pertaining to Notification of Termination. Going forward staff will notify any resident that leaves treatment with a letter identifying the reason the resident is being terminated from treatment and in the letter the appeal process will indicate how the resident can request to be returned to the program. The persons responsible for processing the Termination Letters will be the counselors and Recovery Specialist. A record keeping training will be conducted on July 10, 2015 to ensure the staff is properly trained in completing the termination letter. The Persons Responsible for the training will be the Program Director and Clinical Supervisors. The completion of notification letters will be monitored monthly in CQI meeting to ensure ongoing compliance. The person responsible for CQI monthly monitoring will be the Program Director. |