Observations
Based on the review of client records, the facility failed to ensure that a client shall have the opportunity to request reconsideration of a decision terminating treatment. Client #1 was admitted on September 4, 2025, and discharged on October 31, 2025. There was no documentation in the client record that the client was given an opportunity to request reconsideration of an administrative discharge. This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
Deficiency:
Based on a review of client records, the facility did not ensure documentation demonstrating that a client was provided the opportunity to request reconsideration of a decision terminating treatment.
Client #1 was admitted on September 4, 2025, and administratively discharged on October 31, 2025. The client record did not contain documentation indicating that the client was informed of the right to request reconsideration of the discharge decision. This finding was reviewed with facility staff during the complaint investigation.
Corrective Action for the Client Identified
Client #1 is no longer active in treatment. No corrective action is applicable for this individual.
Corrective Action to Prevent Recurrence
The facility will ensure that clients subject to administrative discharge are informed of their right to request reconsideration of the discharge decision. The facility will reinforce existing administrative discharge procedures to require documentation that this information has been provided to the client.
Staff Education
Clinical and supervisory staff will be reminded of client rights related to treatment termination and the documentation requirements associated with administrative discharge, including the client's right to request reconsideration. This will be completed within 30 days and documented.
Monitoring
The Clinical Supervisor will review administrative discharge documentation as part of routine supervisory oversight to ensure required documentation is present. Any deficiencies identified will be addressed through supervision and corrective guidance.
Responsible Person
Clinical Supervisor, under the oversight of the Executive Director. |