Observations
Based upon an observation during the physical plant inspection, the facility failed to secure client records within a locked storage container.
The findings include:
A physical plant inspection was completed on April 28, 2014. At the time of the physical plant inspection, client records were kept in a filing cabinet located in the tech office. The cabinet was not locked at the time of the inspection. The tech office is used by all staff as this is where the printer, copier and fax machines are located.
The housekeeper, who does not meet the qualifications for a counselor, had access to client records. In addition to her cleaning duties, she also had been completing client aftercare plans with clients and conducting follow-ups.
The findings were confirmed during staff interviews.
|
Plan of Correction
Campus Director will ensure client records are secured behind a double locked system:first locked in their filling cabinets and then locked behind the office door. Campus Director,counseling staff, nursing, admission technician and medical secretary will be the only ones with access to the locked cabinets. Program Director and Clinical Supervisor will check daily for the first 30 days to ensure the cabinets are being locked, and then randomly thereafter.
As of 4/29/14 Campus Director removed access to counselors offices from Employee VB(housekeeper), unless she is supervised by a counselor. Employee VB has no keys to counseling offices or file cabinets. Employee VB has not nor shall ever complete aftercare plans. As of 5/28/14, Clinical staff will contact outside facilities to set up appointments. This will be monitored closely for the next 30 days by the Clinical Supervisor, and then randomly afterword. |