Observations
Based two of three applicable discharged resident records reviewed, the facility failed to provide notification to the emergency contact stating the resident ' s decision to end residency or not returning to the drug and alcohol recovery house as expected.
Resident #5 was admitted on March 7, 2025, and discharged June 25, 2025. The emergency contact was not notified within 12 hours of the resident not returning. The emergency contact was documented for July 16, 2025.
Resident #7 was admitted on May 16, 2025, and discharged August 1, 2025. The emergency contact was not notified within 12 hours of the resident not returning. The emergency contact was documented forAugust 4, 2025.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Discharge Checklist utilized by Program Counselors and Program Therapists to verify and garner approval from a supervisor to finalize the discharge process has been updated to include specific information regarding contacting a client's Emergency Contact and when it must be completed by the clinician as opposed to by supervisory leadership or residential staff as the cause of the missing emergency contacts was due to a lack of clarity in the responsible party depending on the time of the client's discharge.
The Compliance Officer, in collaboration with the Program Director, conducted retraining sessions for Homestead Clinical Leadership, Program Therapists, and Residential Staff during a staff meeting on 8/14/2025. The retraining emphasized the responsibility of clinical team members vs. supervisory leadership vs. residential staff, the update to the Discharge Checklist, and reiterated timeframe expectations of the completion of Emergency Contacts. Particular attention was given to the need to complete the Emergency Contact in all cases and within 12 hours of discharge.
The Compliance Officer has established an additional monthly auditing process, which began on 8/15/2025, to compare the presence of "Emergency Contacts" to Discharge Types to verify that this update was successful. This additional monitoring will continue monthly for six months or until 100% accuracy has been maintained for three months, whichever milestone is achieved first. Further retraining and process improvements will be conducted if errors continue.
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