Observations
The facility failed to ensure privacy so that counseling sessions could not be seen or heard from outside the counseling room. Based on a physical plant inspection, a counseling room on the ground floor facing the parking lot had a window that was not covered, which allowed for sessions to be seen from the outside.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A blind was re-installed in the identified office window the week ending 10/31/2020. Facility Director will check window coverings on an ongoing basis during quarterly safety inspections. |
Observations
The facility failed to document that treatment plans were reviewed and updated at least every 60 days in four of seven out-patient client records reviewed.
Client #8 was admitted May 29, 2019 and was active at the time of inspection. A treatment plan update was completed on February 13, 2020 and a treatment plan update was due no later than April 13, 2020. However, the treatment plan was not completed until May 21, 2020. Additionally, a treatment plan update was completed on July 23, 2020 and a treatment plan update was due no later than September 23, 2020. However, the treatment plan was not completed until October 8, 2020.
Client #9 was admitted July 30, 2019 and was active at the time of inspection. A treatment plan update was completed on May 2, 2020 and a treatment plan update was due no later than July 2, 2020. However, the treatment plan was not completed until September 25, 2020.
Client # 12 was admitted August 5, 2019 and was discharged September 12. A treatment plan update was completed on December 23, 2019 and a treatment plan update was due no later than February 23, 2020. However, the treatment plan was not completed until March 2, 2020. Additionally, a treatment plan update was completed March 2, 2020 and a treatment plan update was due no later than May 2, 2020. However, the treatment plan was not completed at the time of inspection.
Client # 13 was admitted April 15, 2020 and was discharged September 3, 2020. A treatment plan update was completed on June 8, 2020 and a treatment plan update was due no later than August 8, 2020. However, the treatment plan was not completed at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In-service will be held with all clinical staff by 12/31/2020 conducted by Clinical Director to review requirements and policies of treatment plan updates. Each clinical staff in attendance will sign a document identifying completion of treatment plan in-service. Audits will be implemented by quality improvement to review completion timely of treatment plan updates these will continue on a monthly basis. |