Observations
Based on a review of client records, the Accommodation of Service and Emotional Support Animals policy, and administrative documentation, along with staff interviews, the facility failed to house pets in a safe and sanitary manner in three of three charts reviewed.Client # 1 was admitted on April 8, 2026, and discharged on April 18, 2026. This record did not contain a signed Service Animal Expectations form nor proof of up-to-date vaccinations for the client's emotional support dog.Client # 2 was admitted on May 25, 2026, and discharged on May 22, 2026. This record did not contain proof of up-to-date vaccinations for the client's emotional support dog.Client # 3 was admitted on May 18, 2026, and discharged on May 23, 2026. This record did not contain proof of up-to-date vaccinations for the client's emotional support dog.
|
Plan of Correction
The admissions department will ask for current vaccinations on all service animals who may be entering treatment with a patient.
The CEO met with the admission's director on July 2, 2026 to discuss the need to ask for vaccination records. The admission's director made the admission's team aware of the need to ask for vaccinations on this date.
If current vaccinations are unavailable, the CEO will reach out to the Acadia legal department for direction on the admission and approval/denial to admit without current vaccinations. The admission's team will document that current vaccinations were unable to be obtained.
The admissions director will monitor the request for vaccinations on the next 8 service animal referrals. |