Observations
Based on the review of the facility's policy and procedure manual, the facility failed to adhere to its written procedures for the management of treatment rehabilitation services for clients.
The facility ' s " AMA/ASA " policy " WI 003 " notes that at the time of discharge: "the client must sign for their belongings in both KIPU and the Valuables Paper Checklist must be signed and uploaded as an attachment. "
Client #1 was admitted on April 14, 2025, and discharged on April 23, 2025. There was no documentation in the client record that their inventoried belongings were returned at the time of discharge.
This finding was reviewed with facility staff during the complaint investigation process.
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Plan of Correction
Client #1's record was reviewed. Documentation of returned belongings was not present at the time of review. No further corrective action can be taken due to the client no longer being in care. The facility conducted a retrospective audit of discharged clients to identify any records lacking documentation of belongings reconciliation in accordance with Policy WI 003. Any identified deficiencies were addressed through staff follow-up and completion of appropriate late entries.
Staff previously received training on Policy WI 003. This policy has been re-emphasized to all staff with additional expectations for real-time compliance.
Effective immediately, the Valuables Paper Checklist must be completed, signed, and uploaded into KIPU prior to the client leaving the facility. Discharges are not considered complete until this requirement is met.
Supervisors are required to collect all Valuables Paper Checklists and verify that each document has been uploaded into the client record prior to shredding the paper copy.
The discharge process has been strengthened to require full documentation of belongings reconciliation in both KIPU and supporting attachments before finalizing discharge.
The Clinical Supervisor will conduct daily chart audits of all discharges to ensure required documentation is present. Compliance with belongings documentation will be included in the facility's ongoing audit process and tracked daily. Audit findings will be reviewed by leadership, and any deficiencies will result in immediate corrective action and staff re-education. The Clinical Supervisor is responsible for this.
Completion Date:
April 15, 2026 |