Observations
The recovery house failed to notify the resident in writing of a decision to end residency. This is evidenced by the recovery house ' s inability to provide sufficient documentation to the Department when requested. The following documentation was requested by July 9: explanation of the reasons for the resident ' s discharge and all discharge related documentation. On July 13 the Department received some explanation of the resident ' s discharge. The recovery house was given until July 24 to inform of additional clarification needed pertaining to the resident ' s discharge and documentation the resident was notified of their discharge in writing. On July 26 the Department received the requested additional clarification of the resident ' s discharge but did not receive the notification to end resident in writing.
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Plan of Correction
POC
717.23 Notification of decision to end residency. (a) the licensee shall notify the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency. (b) the resident shall have an opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect. (c) the resident may decide to end residency without providing a reason to the licensee.
PROCEDURE
Before the decision is made to end residency, a verbal warning is given, then followed by a written warning (an incident report). Final resort is to end residency (discharge).
a) Staff will give a verbal warning to correct/change area(s) of concern.
b) If the concerns continue, staff will issue a written warning (an incident report) for areas of improvement and a timeframe to correct/change the concerns.
(Copies of the written warning (incident report) must be filed in the resident's file, uploaded to the Box platform for RHI review and approval, and sent to the Director for Master chart storage.)
c) If concerns continue after the incident report, the last resort is to discharge. A discharge form will be completed and uploaded to the Box platform for RHI review and approval. A copy of the discharge will be provided to the resident if present. Copies of the discharge form will also be added to the resident's closed chart and sent to the Director for Master chart storage.
The infractions that lead to immediate discharge are:
1. Using any type of illicit mind-altering substances on the premises.
2. Any form of threats or physical assault towards self, staff, or others.
3. Suicide attempt or verbal intent will be referred to a HLOC
This corrective action plan will go in effect on Monday, August 17, 2026.
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