Observations
Based on one of seven records reviewed, the facility failed to complete a consent to residency, signed by the resident within 24 hours of arrival. Resident # 6 was admitted on December 31, 2025, and was discharged March 13, 2026. The consent to residency was not signed by the resident until January 21, 2026These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
As the resident referenced in this observation has discharged and the consent to residency was already out of date, there is no corrective action to be taken regarding their record.
Client residential records are reviewed by Residential Leadership within 2-4 weeks of client admission to identify patterns of errors with timing, frequency, and completion of vital record elements. Residential Management was trained on 7/2/2026 to shorten the window of this initial review to be required within 3 days of a client admission to ensure that no timebound vital records are completed late.
The Director of Operations was trained on 7/2/2026 to complete a random sample review of clients monthly to verify that this increase in monitoring is successful. Findings are reported to the Compliance Manager and the Compliance Officer quarterly and, as necessary, ad hoc when there are findings of non-compliance. |