Observations
Based on a review of the facility's residential rehab policies and procedures, a review of client records and a review of facility security footage, the facility failed to follow their policy and procedures manual. Client #1 was admitted July 14, 2026, and was discharged on August 12, 2026. The facility ' s " Conducting Patient Observation Rounds " policy notes Behavioral Health Techs/Counselor Aides (CA) must " observe each patient a minimum of ...every 30 minutes on the SUD unit, " DDAP staff reviewed facility rounding sheets and observed the following issues:oJuly 16, 2026 (Detox Q15) 13:45hrs no rounding signatureoJuly 28, 2026 (Rehab Q30) 6:30hrs no rounding signatureoJuly 31, 2026 (Rehab Q30) 14:30hrs no rounding signatureoAugust 1, 2026 (Rehab Q30) 11:00hrs no rounding signatureoAugust 2, 2026 (Rehab Q30) 11:00 hrs. no rounding signatureoAugust 3, 2026 (Rehab Q30) 08:00hrs no rounding signatureoAugust 4, 2026 (Rehab Q30) 06:30hrs, 17:30hrs, 19:30hrs, 20:00hrs. no rounding signaturesoAugust 5, 2026 (Rehab Q30) 12:00hrs, 21:30hrs, no rounding signaturesoAugust 7, 2026 (Rehab Q30) 15:00hrs, 16:00hrs, 20:30hrs, 22:00hrs, no rounding signaturesoAugust 8, 2026 (Rehab Q30) 11:30hrs, no rounding signatureoAugust 9, 2026 (Rehab Q30) 11:00hrs no rounding signatureOn the night of the incident August 12, 2026, the facility reports that rounding sheets were completed for Client #1 between the hours of 1:00a-2:00a; however, upon review of the video rounds for 1:30a were not completed. Additionally, the facility ' s " Emergency Care-Code Blue " policy notes " the person notified of the emergency should announce or have someone announce over the phone system by dialing extension 260 and stating " CODE BLUE. " Review of the facility ' s pre-liminary root cause analysis noted that this did not occur as per policy. These findings were reviewed with facility staff during the unusual incident review.
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Plan of Correction
ACTIONS:
1.On August 12, 2026, the three staff members involved in the incident were placed on administrative leave pending investigation. Following completion of the internal review, it was determined that the staff members did not follow facility policy and all three staff members were terminated.
2.All SUD staff will be reeducated on the facility's Conducting Patient Observation Rounds policy and procedures, to reinforce compliance with all requirements for conducting and documenting patient observation rounds.
3.Leadership will conduct daily patient observation round audits utilizing both in-person observation and camera review to evaluate compliance with required observation rounds and identify deficiencies requiring immediate feedback, reeducation, and/or corrective action as appropriate.
4.The Emergency Care-Code Blue Policy and Procedures were revised to provide additional clarity and guidance regarding the steps and expectations for responding to a medical emergency, including but not limited to, activation of the Code Blue response, initiation of CPR when indicated, AED use, and notification of emergency medical services when indicated. The revised policy was approved through the Medical Executive Committee.
5.All direct care staff will receive retraining on the revised Emergency Care-Code Blue Policy and Procedures, including but not limited to, recognition and response to medical emergencies, timely initiation of CPR when indicated, AED use, activation of the Code Blue response, and notification of emergency medical services when indicated.
6.Code Blue drills will be conducted once per shift, per week to reinforce timely recognition and response to medical emergencies, including initiation of CPR when indicated. Drill frequency will be reevaluated based on demonstrated staff competency and sustained compliance with emergency response expectations.
MONITORING:
1.Patient Observation Rounds: Leadership will conduct daily patient observation round audits utilizing both in-person observation and camera review. Findings will be reviewed daily with leadership, reported through the daily Flash meeting, and reported monthly through the Performance Improvement Committee. Identified deficiencies will result in immediate feedback, reeducation, and/or corrective action as appropriate. Monitoring will remain ongoing, with audit frequency reevaluated based on demonstrated compliance and sustainability.
2.Staff Education: Training compliance for the Conducting Patient Observation Rounds and Emergency Care-Code Blue policies will be tracked until all applicable staff have completed the required education.
3.Code Blue Competency: Staff competency will be evaluated through Code Blue drills conducted once per shift, per week. Following each drill, leadership will evaluate recognition of the medical emergency, timely initiation of CPR when indicated, appropriate AED use, activation of the Code Blue response, notification of emergency medical services when indicated, and required documentation. Identified deficiencies will result in immediate feedback and reeducation. Findings will be reviewed for trends through the Performance Improvement Committee.
RESPONSIBLE: Risk Manager, DON, Staff Educator
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Observations
Based on a review of residential client records, the facility failed to ensure that clients received counseling services according to their individual comprehensive treatment. Client #1 was admitted July 14, 2026, and was discharged on August 12, 2026. The comprehensive treatment plan, dated July 17, 2026, indicated one individual therapy session per week. There was no documentation that Client #1 received an individual therapy session during the week of August 2-8, 2026. This finding was reviewed with facility staff during the unusual incident review.
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Plan of Correction
ACTIONS:
1.All SUD clinical staff will be re-educated on the requirement to provide and document individual counseling services in accordance with the frequency identified on each client's comprehensive treatment plan.
2.Clinical Supervisor will review individual counseling completion to identify clients who have not received individual counseling services at the frequency required by their comprehensive treatment plan and will address identified deficiencies with the assigned clinician.
MONITORING:
1.Training compliance will be tracked by the Clinical Supervisor until all applicable SUD clinical staff have been trained.
2.The Clinical Supervisor will audit 15 charts monthly to verify that individual counseling services were provided and documented in accordance with the frequency established in each client's treatment plan. Identified deficiencies will result in immediate feedback and reeducation. Results will be reported monthly through the Performance Improvement Committee. Monitoring will continue for three months, with duration reevaluated based on demonstrated compliance and sustainability.
RESPONSIBLE: Interim Director of Clinical Services
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