Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of two client records.
The findings include:
Ten client records were reviewed on July 30 - 31, 2014. Two records pertained to clients that were involuntarily terminated from treatment at the project and were required to include written notification of this decision. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in client record # 5.
Client # 5 was admitted into treatment on September 18, 2013 and was involuntarily terminated from treatment at the project on April 21, 2014. Client record # 5 did not include written notification of the decision to involuntarily terminate the client's treatment at the project as of July 31, 2014.
The clinical supervisor was interviewed on July 31, 2014 and confirmed the findings.
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Plan of Correction
709.33(a) LICENSURE
Notification of Termination:
709.33. Notification of termination. (a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
In response to this observation, the four Clinicians will receive re-training effective 8-24-14 from their immediate Clinical Supervisor on the regulatory compliance standards, as well as the methods for notification that MYCS D&A services utilizes, as follows:
It is the expectation that all MYCS D&A service participants receive written notification of any decisions re: involuntary termination. A notification letter is printed, signed by the clinician, and sent via USPS to the approved address on file. A copy of this written notification is to be kept in the participants electronic health record via scanning into Onbase, along with any prior letters that indicate engagement attempts.
It is the current policy that the Clinical Supervisor complete random chart audits from a variety of clinicians on a monthly basis, and reports their findings to the Manager of Behavioral Health as well as to the agency Compliance committee. These audits are inclusive of involuntary discharge notification letters. The Clinical Supervisor is ultimately responsible to ensure that this deficiency does not recur. |