Observations
Based on a physical plant inspection conducted on February 21, 2024, between 10:00 am and 11:00 am, the facility failed to ensure that all heaters were permanently mounted or installed as there was a space heater located in the medical practitioner's office.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director removed the space heater from the medical practitioner's office on February 21, 2024. The executive director and the MAT supervisor will do weekly checks for the next 6-months to ensure compliance with no space heaters. The MAT supervisor will review with the doctor during their team meeting on March 8, 2024. The MAT supervisor will then check monthly beginning September 2024. |
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of seven client records reviewed.Client #1 was admitted May 5, 2020, and was active at the time of inspection. A treatment plan updated was completed on November 20, 2023, and the next update was due no later than January 20, 2024; however, the update was not completed at the time of inspection.Client #2 was admitted September 22, 2023, and was active at the time of inspection. The comprehensive treatment plan was completed on October 2, 2023 and the first update was due no later than December 2, 2023; however, the update was not completed until January 4, 2024.Client #3 was admitted June 2, 2023, and was active at the time of inspection. A treatment plan update was completed on November 30, 2023 and the next update was due no later than January 30, 2024; however, the update was not completed until February 15, 2024Client# 5 was admitted January 5, 2023, and was discharged October 26, 2023. A treatment plan update was completed on March 29, 2023, and the next update was due no later than May 29, 2023; however, the update was not completed until June 14, 2023.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor reviewed in clinical supervision on 3/6/2024. It was explained that all treatment plan updates were due every 60 days, regardless of the date the client signs the form.
A review of clients 1, 2, 3, 5 will be done to ensure that a treatment plan update is completed every 60 days schedule going forward. All clients listed will have their current due treatment plan updates completed by 03/30/2024.
Clinical Supervisor will complete random chart audits monthly beginning 3/11/2024 and will review with counselors the results. |