Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of fire extinguishers upon employment in four of fifteen personnel records reviewed.
The findings include:
Fifteen personnel records requiring the documentation of fire extinguisher training were reviewed during the renewal inspection on February 25, 2015. The facility failed to document the completion of fire extinguisher training upon employment in personnel records #12, 13, 14, and 15.
Employee #12 was hired on 3/17/2014 as a counselor. There was no documentation that employee #12 completed the fire extinguisher training as of the time of the review.
Employee #13 was hired on 5/19/2014 as a counselor. There was no documentation that employee #13 completed the fire extinguisher training as of the time of the review.
Employee #14 was hired on 5/27/2014 as a counselor. There was no documentation that employee #14 completed the fire extinguisher training as of the time of the review.
Employee #15 was hired on 8/5/2013 as a counselor. There was no documentation that employee #15 completed the fire extinguisher training as of the time of the review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (c) (4) LICENSURE
Fire safety.:
705.28. Fire safety. (c) Fire extinguishers. The nonresidential facility shall: (4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
During monthly orientation, the office manager will conduct training on the use of fire extinguishers for all newly hired staff. Previously, staff who work at satellite locations were not included because they o undergo this training at their satellite locations. This was implemented effective March 2, 2015. The office manager will be responsible for ongoing compliance. Compliance will be measured by the inclusion of the signed and dated safety training documents in the safety training logbook.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in six of ten client records reviewed.
The findings include:
Ten client records were reviewed on February 26, 2015. The facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in records, #1, 2, 3, 5, 7, and 10.
Client #1's individual treatment plan dated 8/4/2014 stated that the client was to receive individual counseling sessions weekly. Client #1 received individual counseling sessions on the following dates: 2/12/15, 1/29/15, 1/22/15, 1/15/15, 12/30/14, 12/16/14, 12/2/14, and 11/11/14. The client's treatment plan updates dated for 9/16/14, 12/2/14, and 2/12/15 did not indicate a change in the frequency of the client's individual sessions.
Client #2's individual treatment plan dated 6/13/2014 stated that the client was to receive individual counseling sessions weekly. Client #2 received individual counseling sessions on the following dates: 2/4/15, 1/21/15, 12/3/14, 11/19/14, 11/5/14. The client's treatment plan updates dated for 1/21/15 and 10/3/14 did not indicate a change in the frequency of the client's individual sessions.
Client #3's individual treatment plan dated 6/18/2014 stated that the client was to receive individual counseling sessions weekly. Client #3 received individual counseling sessions on the following dates: 2/12/15, 1/29/15, and 1/8/15. The client's treatment plan updates dated for 1/13/15, 9/23/14, and 7/16/14 did not indicate a change in the frequency of the client's individual sessions.
Client #5's individual treatment plan dated 11/10/2014 stated that the client was to receive individual counseling sessions weekly. Client #5 received individual counseling sessions on the following dates: 2/9/15, 1/27/15, and 1/8/15. The client's treatment plan update did not indicate a change in the frequency of the client's individual sessions.
Client #7's individual treatment plan dated 9/11/2014 stated that the client was to receive individual counseling sessions weekly. Client #7 received an individual counseling session on 11/14/14. The next individual session for Client #7 was on 12/31/14. The client's treatment plan updates did not indicate a change in the frequency of the client's individual sessions.
Client #10's individual treatment plan dated 7/23/14 stated that the client was to receive individual counseling sessions weekly. Client #10 received individual counseling sessions on the following dates: 10/1/14, 9/10/14, 8/27/14. and 8/13/14. The client's treatment plan update did not indicate a change in the frequency of the client's individual sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92(c) LICENSURE
Treatment and rehabilitation services:
709.92. Treatment and rehabilitation services. (c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
The treatment plan update document that is currently in use will be modified to include the frequency of treatment for both individual and group sessions. The frequency of treatment is already included in the treatment plan, but was not included in the treatment plan update. This was implemented by the IT department on March 26, 2015. The clinical staff was instructed on the use of this via email and in the clinical team meeting on March 26, 2015. There will be additional training with the clinical staff concerning the frequency of treatment sessions and documenting missed and cancelled appointments. The training will include the importance of the frequency documented in the treatment plan matching the actual treatment episodes. The clinical supervisors will be responsible for ongoing compliance with the use of the updated treatment plan updates and the frequency of treatment as per the treatment plan. Compliance will be measured by ongoing random chart reviews, which will be conducted on a monthly basis. The training will be completed by April 9, 2015.
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