Observations
The facility failed to document written acknowledgement by the client that they were notified of all of their rights in six of six client records reviewed on October 19-20, 2017.
There was no documentation that the client was informed that the project, facility of clinical director may temporarily remove portions of the records prior to the inspection, if determined detrimental; reason for removal would be documented in the client's record; client has a right to appeal the decision to remove information and that the client had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record in client records # 1, 2, 3, 4, 5 and 6.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Division Director will review and adjust agency policy as needed to ensure all required client rights are listed in rights that are reviewed with clients upon admission. Division Director will complete this review by 11/14/2017.
Division Director will review agency policy/client rights with the Program Director by 11/17/2017.
Program Director will review updated policy/client rights with all staff by 11/21/2017.
Staff will begin using updated policy/client rights with all clients starting 11/22/2017.
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