Observations
Based on a review of the facility policy and procedure for staff development, including the submitted update, the facility failed to address the policy and procedure for the development of the overall training plan and evaluation of the previous year ' s training plan.This finding was reviewed with facility staff during the licensing inspection.This is a repeat citation from the annual inspection completed on April 29, 2022.
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Plan of Correction
The facility revised the policy and procedure for staff development to include the Program Manager and Associate Director of Behavioral health as being responsible for completing the annual evaluation by December 31st of each year.
The overall plan and implementation will be monitored by quarterly. Program Manager will provide a report in regular supervision monthly to ensure the plan is being completed and followed.
Person Responsible: Program Manager ,Associate Director of Behavioral Health
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Observations
Based on applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in six of six records. The facility policy and procedure manual indicates case consultations are to be completed upon admission and every sixty days thereafter. Client #1 was admitted on May 24, 2022 and discharged on January 27, 2023. A case consultation was due to occur no later than July 24, 2022. There was no case consultation documented in the client record.Client #2 was admitted on March 28, 2022 and discharged on December 20, 2022. A case consultation was due to occur no later than August 26, 2022, however a case consultation was not documented in the client record until September 26, 2022.Client #4 was admitted on March 29, 2022 and discharged on March 6, 2023. A case consultation was due to occur no later than August 27, 2022. There was no case consultation documented in the client record.Client #5 was admitted on February 16, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than July 17, 2022, however a case consultation was not documented in the client record until August 14, 2022.A case consultation was due to occur no later than October 14, 2022, however a case consultation was not documented in the client record until November 13, 2022. A case consultation was due to occur no later than January 13, 2023, however a case consultation was not documented in the client record until February 11, 2023.Client #6 was admitted on March 7, 2022 and still active at the time of the inspection. A case consultation was due to occur no later than August 5, 2022, however a case consultation was not documented in the client record until September 4, 2022.A case consultation was due to occur no later than November 4, 2022, however a case consultation was not documented in the client record until December 5, 2022.A case consultation was due to occur no later than February 5, 2023. There was no case consultation documented in the client record.Client #7 was admitted on August 19, 2021 and still active at the time of the inspection. A case consultation was due to occur no later than July 16, 2022, however a case consultation was not documented in the client record until August 14, 2022.A case consultation was due to occur no later than October 16, 2022, however a case consultation was not documented in the client record until November 13, 2022.A case consultation was due to occur no later than January 13, 2023, however a case consultation was not documented in the client record until February 20, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed case consultation time frames with staff to ensure information was provided to all staff.
Program Manager will review charts monthly to ensure documentation is completed per the agency's established time line.
Responsible Person: Program Manager
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