Home Base

Deficiency cited, re-licensure survey : C 149 Human Rights Committee

Based on documentation review and interview, the Provider failed to ensure the human rights committee was composed of one-third consumers and/or designated legal representatives to make up at least one-third of the committee membership with no more than one-third staff members of the Provider. This deficient practice has the potential to affect all consumers served by the Provider. Findings include: (a) Documentation review of the Human Rights Committee meeting minutes, dated 11/01/23, revealed four (4) individuals were documented as present, with no members documented as absent, at the meeting. The four (4) members present were all staff of the Provider. There was no documented evidence that any consumers and/or designated legal representatives attended the meeting. (b) Review of the Provider's policies titled "Human Rights Committee Manual," revealed "The Committee is comprised of at least six members. Members will have expertise in at least one of the following areas: social work, behavioral health, child welfare and two members will consist of current or previous clientele." (c) Interview on 02/19/25 at 9:15 a.m. with Staff P, Human Resources Systems Specialist, confirmed the Human Rights Committee meeting held on 11/01/23 documented four (4) staff were and no consumers attended.

Deficiency cited, re-licensure survey : C 142 Human Rights Committee

Based on documentation review and interview, the Provider failed to ensure the establishment and implementation of a Human Rights Committee for the year 2024. This deficient practice has the potential to affect all consumers served by the Provider. Findings include: (a) Documentation review on 02/19/025 revealed no documented evidence of a Human Rights Committee for the year 2024. In addition to this cited deficiency, the Provider is also not in compliance with the following regulations: \'a764-11-5.3.1.b. through \'a764-11-5.3.4. (b) Review of the Provider's policy titled "Human Rights Committee Manual," revealed "The committee shall meet at least once each calendar year." (c) Interview on 01/19/25 at 9:15 a.m. with Staff P, Human Resources System Specialist confirmed the agency had no Human Rights Committee established for the year 2024.

Deficiency cited, re-licensure survey : C 383 Initial Plan for Service

Based on documentation review and interview, the Provider failed to ensure that consumers had a written, initial plan of care developed and entered into the consumer's record within seven (7) days of admission for 15 of 62 consumers (Consumer #1, #9, #11, #12, #15, #16, #18, #19, #21, #22, #23, #24, #28, #31 and #43) in the sample. Findings include: (a) Review of the records for Consumer #1, #9, #11, #12, #15, #16, #18, #19, #21, #22, #23, #24, #28, #31 and #43, admitted 7/30/24, 7/27/24, 7/2/24, 1/30/24, 5/7/24, 12/17/24, 9/12/23, 8/27/24, 6/21/24, 1/31/25, 10/31/24, 1/7/25, 9/25/24, 7/8/24 and 9/5/24, respectively, revealed no documented evidence of a written, initial plan of care developed and entered into the consumer's record within seven (7) days of admission. (b) Interview on 2/19/25 at 10:30 a.m. with Staff P, Human Resources Systems Specialist, confirmed that a written, initial plan of care for Consumer #1, #9, #11, #12, #15, #16, #18, #19, #21, #22, #23, #24, #28, #31 and #43 was not available.

Deficiency cited, re-licensure survey : C 381 Planning for Services

Based on documentation review and interview, the Provider failed to ensure written consents were obtained prior to treatment and documented in the consumer's records, nor was there documentation to indicate the reason written consent was not obtained for nine (9) of 62 consumers (Consumer #5, #6, #13, #16, #22, #46, #49, #52 and #54) in the sample. Findings include: (a) Review of the records for Consumer #5, # 6, #13, #16, #22, #46, #49, #52 and #54, admitted 8/17/24, 10/4/24, 9/21/24, 12/17/24, 1/31/25, 2/29/24, 9/19/24, 4/4/24 and 11/21/24, respectively, revealed no documented evidence of signed written consents. (b) Interview on 2/19/25 at 10:30 a.m. with Staff P, Human Resources System Specialist, confirmed that written consent for treatment for Consumer #5, #6, #13, #16, #22, #46, #49, #52 and #54 was not available.

Deficiency cited, re-licensure survey : C 201 Consumer Record Maintenance

Based on documentation review and interview, the Provider failed to obtain proof of decision- making for two (2) of three (3) consumers (Consumers #12 and #33) in the sample who are underage, not emancipated, and have court- appointed legal guardians, as the Provider obtain written, signed consents for treatment and services for Consumer #12 and #33 from the purported designated legal representatives despite having no documented evidence of decision-making appointment. Findings include: (a) Review of Consumer #12's initial assessment document, entitled Assessment and Initial Plan of Service, dated 01/31/23, revealed his physical and mental health diagnoses, identified needs, and planned services. Furthermore, the document revealed a signed, written consent by the West Virginia Department of Health and Human Resources (WVDHHR) in lieu of Consumer #12's signature, or alternatively, a parent's signature. (b) Review of the electronic medical record for Consumer #12 revealed the following: (i) Consumer #12 was admitted to services on 01/31/23. (ii) 10/12/07 is Consumer #12's date of birth; he is a minor. (iii) There were no court orders regarding the purported legal guardianship appointment of the WVDHHR, which contrasted with interviews that confirmed WVDHHR was, at the time of the present survey, serving as the designated legal representative for Consumer #12. (c) Review of Consumer #33's initial assessment document, entitled Assessment and Initial Plan of Service, dated ...

Deficiency cited, re-licensure survey : C 142 Human Rights Committee

Based on documentation review and interview, the Provider failed to establish and maintain a human rights committee, and therefore, the efficacy of the protection of consumer rights could not be evaluated. This deficient practice has the potential to affect all consumers served by the Provider. Findings include: (a) Request for documentation related to a Human Rights Committee revealed there was no documented evidence of a Human Rights Committee. In addition to this cited deficiency, the Provider is also not in compliance with the following regulations: \'a764-11-5.3.1.b. through \'a764-11-5.3.4. (b) Review of the Provider's Human Rights Committee policy, undated but presented as current, subsection 10.2.b Safety, revealed "A quarterly review by the Human Rights Committee will be held whose primary function is to assist the Center in the promotion and protection of a consumer's rights, and to review, approve and monitor individual programs designed to manager inappropriate behaviors and other program that are intrusive or involve risks to a consumer's protection and rights." (c) Interview on 5/9/23 at 10:30 a.m. with Staff M, Human Resource Systems Specialist, confirmed that the Provider does not have a Human Rights Committee serving the needs of its behavioral health consumers.

Deficiency cited, re-licensure survey : C 102 64-11-5.2.a. Governing Body

Based on documentation review and interview, the governing body failed to ensure the accountability of the Center. Findings include: (a) The Center failed to ensure it does not employ individuals with a conviction of consumer or child abuse or neglect. Staff affected: one (1) of one (1) contracted staff in the sample. Staff identifier: E. (Refer to C143) (b) The Center failed to maintain a personnel record that includes employee performance evaluations for all staff. Staff affected: three (3) of three (3) staff in the sample who were employed over a year. Staff identifiers: A, B and F. (Refer to C150) (c) The Center failed to ensure that beginning on the first day of employment, professional and direct care staff shall begin orientation and training on treatment policies and procedures, consumer rights and the use of emergency procedures, such as crisis intervention and restraints. Staff affected: five (5) of six (6) staff in the sample. Staff identifiers: Staff A, C, D, E and F. (Refer to C152) (d) The Center failed to maintain a human rights committee to hold meetings and keep written minutes of all meetings, including the names and titles of all members and guests present and members absent. Consumers affected: all consumers served by the Center. (Refer to C159)

Deficiency cited, re-licensure survey : C 103 64-11-5.2.b. Governing Body

Based on documentation review and interview, the Center failed to evaluate implementation of policies. Findings include: (a) The Center failed to ensure it does not employ individuals with a conviction of consumer or child abuse or neglect. Staff affected: one (1) of one (1) contracted staff in the sample. Staff identifier: E. (Refer to C143) (b) The Center failed to maintain a personnel record that includes employee performance evaluations for all staff. Staff affected: three (3) of three (3) staff in the sample who were employed over a year. Staff identifiers: A, B and F. (Refer to C150) (c) The Center failed to maintain a human rights committee to hold meetings and keep written minutes of all meetings, including the names and titles of all members and guests present and members absent. Consumers affected: all consumers served by the Center. (Refer to C159)

Deficiency cited, re-licensure survey : C 143 64-11-5.6.b. Personnel

Based on documentation review and interview, the Center failed to ensure it does not employ individuals with a conviction of consumer or child abuse or neglect. Staff affected: one (1) of one (1) contracted staff in the sample. Staff identifier: E. Findings include: (a) The Center's policy, Title: Staff Background Check (Fingerprinting), Policy #: GENMAP 5030(A), states: "Procedure: HBI [Home Base, Incorporated] ensures that any and all direct care staff complete at a minimum, State-Level Criminal Background Checks provided by West Virginia CARES, which are fingerprint based." (b) Review of the "Letter of Agreement Between Home Base Inc. and [Staff E, Contract Psychologist]," signed and dated 08/25/17, revealed: "H. Complete Background screening in accordance with WV Statutes in terms of (WV Cares) screenings." (c) Review of the personnel record for Staff E, Contracted Psychologist, revealed no documented evidence of an inquiry to, or report from, WV CARES. (d) Interview on 05/23/18 at 1:40 p.m. with Staff H, Human Resource Director, confirmed that Staff G, Contracted Psychologist, was the Center's only contracted employee and the Center did not contact WV CARES prior to his employment and stated she "did not realize that it was in his contract." (e) The failure of the Center to complete a background screening for their contracted staff does not meet the intent of the regulation that the Center shall not employ individuals with a conviction of consumer or child abuse or ...

Deficiency cited, re-licensure survey : C 150 64-11-5.6.d.6. Personnel

Based on documentation review and interview, the Center failed to maintain a personnel record that includes employee performance evaluations for all staff. Staff affected: three (3) of three (3) staff in the sample who were employed over a year. Staff identifiers: A, B and F. Findings include: (a) The Center's policy, Title: Job Performance, Policy #: GENMED 110; states: "Procedure: Home Base Inc. will conduct annual performance evaluations for all Full, Part-time and Contractual staff." (b) Review of the personnel record for Staff A, Clinician, date of hire 03/28/17, revealed no documented evidence of an annual performance evaluation. (c) Review of the personnel record for Staff B, Clinician, date of hire 02/12/12, revealed no documented evidence of an annual performance evaluation. (d) Review of the personnel record for Staff F, Clinical Director/Behavioral Health, date of hire 05/02/16, revealed no documented evidence of an annual performance evaluation. (e) Interview on 05/22/18 at 1:40 p.m. with Staff H, Human Resource Director, confirmed that Staff A, B and F did not have documented evidence of performance evaluations in their personnel records, and stated, "We don't have anything in place in order to do performance evaluations." (f) The failure of the Center to follow their policy and conduct annual performance evaluations in order to ensure staff are competent in performing their duties does not meet the intent of the regulation that for all staff, the Center shall ...

Deficiency cited, re-licensure survey : C 152 64-11-5.7.a. Staff Training

Based on documentation review and interview, the Center failed to ensure that beginning on the first day of employment, professional and direct care staff shall begin orientation and training on treatment policies and procedures, consumer rights and the use of emergency procedures, such as crisis intervention and restraints. Staff affected: five (5) of six (6) staff in the sample. Staff identifiers: Staff A, C, D, E and F. Findings include: (a) Review of the Center's policies and procedures revealed no documented evidence of a policy regarding orientation training. (b) Review of a list titled "Orientation Topics" provided by the Center included "Client Rights," but no crisis intervention and restraint training. (c) Review of the personnel record for Staff A, Clinician, date of hire 03/28/17, revealed no documented evidence of training for crisis intervention and restraints. (d) Review of the personnel record for Staff C, Case Management Supervisor, date of hire 04/09/18, revealed no documented evidence of training for crisis intervention and restraints. (e) Review of the personnel record for Staff D, Clinician / Socially Necessary Services, date of hire 06/19/17, revealed no documented evidence of training for crisis intervention and restraints. (f) Review of the personnel record for Staff E, Contract Psychologist, date of hire 08/25/17, revealed no documented evidence of training for crisis intervention and restraints or consumer rights. (g) Review of the personnel record ...

Deficiency cited, re-licensure survey : C 159 64-11-5.9.a.1. Human Rights Committee

Based on documentation review and interview, the Center failed to maintain a human rights committee to hold meetings and keep written minutes of all meetings, including the names and titles of all members and guests present and members absent. Consumers affected: all consumers served by the Center. Findings include: (a) There was no documented evidence of a human rights committee meeting being held. (b) The Center's policy, 10.2.b Safety, states: "10.2.b.1 A quarterly review by the Human Rights Committee will be held whose primary function is to assist the Center in the promotion and protection of the consumer's rights, and to review, approve and monitor individual programs designed to manager inappropriate behaviors and other program that are intrusive or involve risks to a consumer's protection and rights." (c) Interview on 5/23/18 with Staff G, Chief Executive Officer, confirmed that even though there is a policy for human rights committee meetings, the Center has not held a human rights committee meeting for the behavioral health services provided, and has only held meetings for the children's homes the agency operates. (d) The failure of the Center to have a human rights committee and hold meetings does not meet the intent of the regulation that the Center shall maintain a human rights committee to: Hold meetings and keep written minutes of all meetings, including the names and titles of all members and guests present and members absent.

Deficiency cited, re-licensure survey : C 102 64-11-5.2.a. Governing Body

(1) Based on documentation review and interview, the governing body failed to ensure the accountability of the Center. Findings include: (a) The Center failed to ensure that it does not employ individuals with a conviction of consumer or child abuse or neglect. Staff affected: one (1) of two (2) personnel records (Staff A) reviewed (refer to C143). (b) The Center failed to maintain a personnel record that includes the job description for all staff. Staff affected: one (1) of two (2) personnel records (Staff A) reviewed (refer to C145). (c) The Center failed to maintain a personnel record that includes references for all staff. Staff affected: one (1) of two (2) personnel records (Staff B) reviewed (refer to C147). (d) The Center failed to ensure that professional and direct care staff have training on consumer rights and the use of emergency procedures. Staff affected: two (2) of two (2) personnel records (Staff A and B) reviewed (refer to C152). (e) The Center failed to ensure consumer records contain legal representative documents. Consumers affected: four (4) of four (4) consumers (Consumer #2 through #5) in the sample who were minors (refer to C215).

Deficiency cited, re-licensure survey : C 143 64-11-5.6.b. Personnel

Based on documentation review and interview, the Center failed to ensure that it does not employ individuals with a conviction of consumer or child abuse or neglect. Staff affected: one (1) of two (2) personnel records reviewed. Staff identifier: A. Findings include: (a) Review of the personnel record of Staff A, State Director revealed no evidence of a criminal background check. (b) During interview on 9/12/16 at 12:15 p.m., Staff C, Human Resources Manager confirmed that the Center could not provide documented evidence that a criminal background check was conducted for Staff A, State Director. (c) Although Staff A is employed as the Center's State Director, the Center could not provide documented evidence that a criminal background check was completed on him. This does not meet the intent of the regulation requiring the Center to ensure that it does not employ individuals with a conviction of consumer or child abuse or neglect.

Deficiency cited, re-licensure survey : C 145 64-11-5.6.d.1. Personnel

Based on documentation review and interview, the Center failed to maintain a personnel record that includes the job description for all staff. Staff affected: one (1) of two (2) personnel records reviewed. Staff identifiers: A. Findings include: (a) Review of the personnel record of Staff A, State Director revealed that he has been employed by the Center since 5/1/16 and there was no evidence of a job description for him. (b) During interview on 9/12/16 at 12:15 p.m., Staff C, Human Resources Manager confirmed that the Center could not provide documented evidence that the Staff A, State Director received a copy of his job description. (c) Although Staff A is employed as the State Director, the Center could not provide documented evidence that he has received a copy of his job description. The Center's failure to provide Staff A with a job description does not meet the intent of the regulation requiring the Center to maintain a personnel record that includes the job description for all staff.

Deficiency cited, re-licensure survey : C 147 64-11-5.6.d.3. Personnel

Based on documentation review and interview, the Center failed to maintain a personnel record that includes references for all staff. Staff affected: one (1) of two (2) personnel records reviewed. Staff identifiers: B. Findings include: (a) Review of the personnel record of Staff B, Counselor revealed that she has been employed by the Center since 7/15/16 and there was no evidence that the Center checked her personal references prior to employment. (b) During interview on 9/12/16 at 12:15 p.m., Staff C, Human Resources Manager confirmed that the Center could not provide documented evidence that the Center conducted personal reference checks prior to the employment of Staff B, Clinical Counselor. (c) Although Staff B is employed as a Counselor, the Center could not provide documented evidence that the Center checked her personal references prior to employment. The Center's failure to check the personal references of Staff B does not meet the intent of the regulation requiring the Center to maintain a personnel record that includes references for all staff.

Deficiency cited, re-licensure survey : C 152 64-11-5.7.a. Staff Training

Based on documentation review and interview, the Center failed to ensure that professional and direct care staff have training on consumer rights and the use of emergency procedures. Staff affected: two (2) of two (2) personnel records reviewed. Staff identifiers: A and B. Findings include: (a) Review of the personnel record of Staff A, State Director revealed no documented evidence that he was trained on consumer rights or crisis intervention. (b) Review of the personnel record of Staff B, Counselor revealed no documented evidence that she was trained on consumer rights or crisis intervention. (c) During interview on 9/12/16 at 12:15 p.m., Staff C, Human Resources Manager confirmed that the Center could not provide documented evidence that Staff A, State Director or Staff B, Counselor had received training on consumer rights or crisis intervention. (d) Although Staff A is employed as the State Director and Staff B is employed as a Counselor, the Center could not provide documented evidence that either received training on consumer rights or crisis intervention. The Center's failure to provide Staff A and Staff B with training on consumer rights or crisis intervention does not meet the intent of the regulation requiring the Center to ensure that professional and direct care staff have training on consumer rights and the use of emergency procedures.

Deficiency cited, re-licensure survey : C 215 64-11-6.8.b.7. Consumer Records

Based on documentation review and interview, the Center failed to ensure consumer records contain legal representative documents. Consumers affected: four (4) of four (4) consumers in the sample who were minors. Consumer identifiers: #2 through #5. Findings include: (a) Review of Consumer #2's clinical record revealed that the consumer is a minor and her biological mother signed documents including but not limited to: a release of information, a consumer rights acknowledgement document, and an informed consent for treatment document, all dated 8/3/16. (b) Review of Consumer #3's clinical record revealed that the consumer is a minor and his biological mother signed documents including but not limited to: a release of information, a consumer rights acknowledgement document, and an informed consent for treatment document, all dated 8/3/16. (c) Review of Consumer #4's clinical record revealed that the consumer is a minor and her grandmother signed documents including but not limited to: a consumer rights acknowledgement document and an informed consent for treatment document, both dated 8/10/16. (d) Review of Consumer #5's clinical record revealed that the consumer is a minor and her grandmother signed documents including but not limited to: a release of information, a consumer rights acknowledgement document, and an informed consent for treatment document, all dated 8/24/16. (e) During interview on 9/12/16 at 11:30 a.m., Staff B, Counselor confirmed that Consumer #2 through #5 ...

Deficiency cited, survey : C 143 64-11-5.6.b. Personnel

Based on review of personnel records and staff interview, the Center has not ensured that it shall not employ individuals with a conviction of consumer or child abuse or neglect for six (6) of six (6) personnel records reviewed (Staff #1, #2, #3, #4, #5 and #6). Findings include: (a) There were no criminal background checks to determine if personnel employed have a conviction of consumer or child abuse or neglect in six (6) files reviewed: (i) Staff #1 - Resident Counselor hired March 2000; (ii) Staff #2 - Resident Counselor hired 9/17/00; (iii) Staff #3 - Clinical Director hired 5/19/99; (iv) Staff #4 - Site Director, changed from a contracted service to an employee 9/21/00; (v) Staff #5 - Resident Counselor hired 1/15/01; (vi) Staff #6 - Resident Counselor hired 8/20/01. (b) The Executive Director acknowledged a lack of such checks for the six (6) personnel files reviewed during an interview on 10/31/01 at 3:30 p.m.

Deficiency cited, survey : C 153 64-11-5.7.b. Staff Training

Based on review of personnel records and staff interview, the Center has not ensured that all direct care staff shall be trained in first aid, cardiopulmonary resuscitation and Heimlich's maneuver as part of staff orientation for two (2) of two (2) employees hired in 2001 (Staff #5 and #6). Findings include: (a) There was no record of any staff training in cardiopulmonary resuscitation and Heimlich's maneuver as part of staff orientation for two (2) files reviewed: (i) Staff #5 - Resident Counselor hired 1/15/01; and (ii) Staff #6 - Resident Counselor hired 8/20/01. (b) There was no record of any staff training in first aid as part of staff orientation for one (1) file reviewed: (i) Staff #6 - Resident Counselor hired 8/20/01. (c) During discussion of the personnel files with the Executive Director on 10/31/01 at 3:30 p.m., he was not able to provide any documentation that such training occurred during the orientation for the two (2) employees. 64-11-5.9.a.1. Human Rights Committee

Deficiency cited, survey : C 159

Based on review of the policy manual and interview with the Executive Director, the Center has not kept written minutes of all human rights committee meetings, including the names and titles of all members and guests present and members absent. Findings include: (a) Review of the manual provided by the Executive Director revealed a description of the human rights committee (HRC) on Page 18. The written description included that the HRC is to "meet quarterly.... minutes will be kept of the content and outcome..." (b) Interview with the Executive Director on 10/31/01 at 12:00 noon, revealed the human rights committee has met twice and reviewed two (2) restraints used. However, the Executive Director stated he does not have any written minutes of the two meetings.

Deficiency cited, survey : C 178 64-11-6.1.f. Health and Safety

Based on observation, the Center has not posted by the telephone in all direct care and residential service locations, emergency telephone numbers for the fire department and local police in the Upshur County residential site. Findings include: (a) Observation of the Upshur County Group Home on 10/31/01 at 2:30 p.m. with a residential counselor revealed there were no postings by the two (2) telephones in the residential site of emergency telephone numbers for the fire department, and the local police.

Deficiency cited, survey : C 186 64-11-6.4.b. Structures, Grounds, Equipment

Based on observation and staff interview, the Center has not kept two (2) bathroom floors, where the toilets are, in good repair at the Lewis County Group Home. Findings include: (a) On 11/1/01 at 9:00 a.m. observation of the bathroom in the residential site occurred. The bathroom has three (3) rooms connected by doors: two (2) rooms each containing a toilet and sink, and one room in between that contains the tub/shower. The tile in the first room, that has a toilet and sink and is located off the hallway, has foot square white tiles that were loose and broken with one (1) tile that was completely unglued (located in front of the toilet); the wooden floor under the linoleum was exposed in more than three (3) areas on the floor. The second room, that has a toilet and sink and is located off the consumer's bedroom, has linoleum around the toilet that has been torn and is now exposing the particle floorboard underneath. Also, a torn linoleum area (approximately 8 by 11 inch triangular shape) between the sink and the toilet is exposing the particle floorboard underneath. (b) Interview with the Site Director on 11/1/01 at 10:00 a.m., revealed that there was carpet covering the bathroom floor when the home was purchased. When the carpet was removed, the floor's condition was essentially as observed on 11/1/01.

Deficiency cited, survey : C 252 64-11-7.3.g.4. Treatment Plan

Based on record review and staff interview, the Center has not ensured that: A treatment plan provides for the review of drug dosages and types and explains the rationale for changes or continuation of psychotropic drugs regimens for two (2) of three (3) consumer records reviewed who were on psychotropic drugs regimens (Consumers #2 and #11). Findings include: (a) A review of consumers who were receiving psychotropic drugs revealed: (i) Consumer #2's 7 day and 30 day treatment plans (dated 5/9/01 and 6/5/01 respectively) had nothing about the psychotropic drugs the consumer was currently taking - Prozac and Zyprexa. However, the medication administration records (MARs) for May and June 2001 document that the consumer took Prozac 20 mg at night and Zyprexa 5 mg at bedtime. (ii) Consumer #11's individual program plan (IPP) dated 6/5/01 had nothing about the psychotropic drugs the consumer was currently taking - Adderall and Trazodone. However, the MARs for June 2001 document that the consumer took Adderall 30 mg daily and Trazodone 50 mg daily. The treatment plan review of 8/15/01 had nothing about the psychotropic drugs the consumer was currently taking, yet a medication change was noted in the progress notes of 7/01 ("on new medication Risperdal...changed to Depakote 7/16/01..."). (b) The Site Director of the Lewis County site acknowledged on 11/01/01 at 10:45 a.m., that there was nothing regarding the psychotropic drugs regimens of Consumer #11 in the treatment plan nor in ...

Deficiency cited, survey : C 260 64-11-7.5.b.1. Consumer Discharge

Based on discharge record review and staff interview, the Center has not ensured that a written discharge summary is entered in a consumer's record within thirty (30) days of discharge and include: The reasons for discharge. This occurred in one (1) of two (2) discharge records reviewed (Consumer #9). Findings include: (a) Consumer #9 was discharged from the Upshur County residential site on 9/07/01. When the record was reviewed on 10/31/01, there was no written discharge summary in the consumer's record. (b) During an interview with the Executive Director on 10/31/01 at 3:00 p.m., he acknowledged that there was no written discharge summary in Consumers #9's record.