Newport Academy – Port Townsend

Deficiency cited, routine inspection : 0675 Personnel-Agency record requirements WAC 246-341-0510(1)(a) A behavioral health agency must maintain a personnel record for each person employed by the age

Based on interview, policy and procedure review, and personnel record review, the agency failed to ensure all staff had a signed position description in the personnel records. Failure to ensure a signed position description in the personnel file can lead to missed staff responsibilities and can lead to client harm. 1. Review of the personnel records for Staff G, Care Coordinator, showed that there was no signed position description in their personnel file. 2. During an interview with Staff I, Human Resources (HR) Generalist, on 01/29/25 at 01:00 PM, they stated, “It looks like we do not have a signed position description.” 3. Review of the policies and procedures titled, “Agency Personnel Record Requirements”, updated 11/01/23, states the agency will maintain a current, signed job description for all staff.

Deficiency cited, routine inspection : 0730 Personnel-Agency record requirements WAC 246-341-0510(1(f) A behavioral health agency must maintain a personnel record for each person employed by the agen

Based on interview, policy and procedure review, and personnel record review, the agency failed to ensure all staff had a copy of their current credential in the personnel records. Failure to ensure staff are credentialed may lead to poor client outcomes. 1. Review of the personnel records for Staff D, Clinical Director, showed there was no record of a current credential in the personnel record. 2. During an interview with Staff I, Human Resources (HR) Generalist, on 01/29/25 at 01:00 PM, they verified there was no record of a current credential in the personnel record and stated, “I am not seeing [their] most current one in the file.” 3. Review of the policies and procedures titled, “Agency Personnel Record Requirements”, updated 11/01/23, states the personnel record must have a copy of the staff member's valid current credential issued by the department if they provide clinical services.

Deficiency cited, routine inspection : 0925 Individual service record content WAC 246-341-0640(1)(a) A behavioral health agency is responsible for the components and documentation in an individual's

Based on clinical record review and interview, the agency failed to provide documentation that individuals received a copy of counselor disclosure requirements as required for the counselor credential for 4 of 4 clinical records reviewed (Client #1-#4). Failure to ensure all clients receive the counselor disclosure requirements and show documentation in the clinical record may result in clients not choosing counselors who best suit their needs and can result in poor client outcomes. 1. Review of the clinical record for Client #1, Client #2, Client #3, and Client #4 showed they did not contain a counselor disclosure as required for the counselor’s credential. 2. During an interview with Staff E, Administrator, on 12/03/24 at 2:28 PM, they stated, “We have it on the wall, just not a detailed copy for the clients.” each deficiency listed on the inspection report form. Your receipt of the list of deficiencies. description of the methods to correct each deficient practice regulation is met. following elements: plan of correction for the specific deficiency cited; the plan of correction is effective and that specific deficiency implementing the acceptable plan of correction. is not acceptable. If a deficiency has already been corrected, was accomplished), possible recurrence of the deficiency. realistic and coinciding with the amount of time your facility and monitored appropriately. Some deficiencies may require replacement of equipment, etc., may need more time reasonable and ...

Deficiency cited, routine inspection : 0780 Management of human resources WAC 246-337-050(7)(d) (7) The licensee shall have written documentation for each staff member including: (d) Current signed j

Based on interview, policy and procedure review, and personnel record review, the agency failed to ensure all staff had a signed position description in the personnel records. Failure to ensure a signed position description in the personnel file can lead to missed staff responsibilities and can lead to client harm. 1. Review of the personnel records for Staff G, Care Coordinator, showed that there was no signed position description in their personnel file. 2. During an interview with Staff I, Human Resources (HR) Generalist, on 01/29/25 at 01:00 PM, they stated, “It looks like we do not have a signed position description.” 3. Review of the policies and procedures titled, “Agency Personnel Record Requirements”, updated 11/01/23, states the agency will maintain a current, signed job description for all staff.

Deficiency cited, routine inspection : 0790 Management of human resources WAC 246-337-050(7)(f) (7) The licensee shall have written documentation for each staff member including: (f) Current license,

Based on interview, policy and procedure review, and personnel record review, the agency failed to ensure all staff had a copy of their current credential in the personnel records. Failure to ensure staff are credentialed may lead to poor client outcomes. 1. Review of the personnel records for Staff D, Clinical Director, showed there was no record of a current credential in the personnel record. 2. During an interview with Staff I, Human Resources (HR) Generalist, on 01/29/25 at 01:00 PM, they verified there was no record of a current credential in the personnel record and stated, “I am not seeing his most current one in the file.” 3. Review of the policies and procedures titled, “Agency Personnel Record Requirements”, updated 11/01/23, states the personnel record must have a copy of the staff member's valid current credential issued by the department if they provide clinical services.

Deficiency cited, routine inspection : 0805 Management of human resources WAC 246-337-050(7)(i) (7) The licensee shall have written documentation for each staff member including: (i) Current driver's

Based on interview and personnel record review, the agency failed to ensure all appropriate staff had current driver’s licenses. Failure to ensure a current driver’s license may result in unauthorized staff transporting clients. 1. Review of the personnel records for Staff D, Clinical Director, Staff G, Care Coordinator, and Staff H, Experiential Therapist, showed they did not have a current driver’s license in the personnel file. 2. During an interview with Staff I, Human Resources (HR) Generalist, on 01/29/25 at 01:00 PM, they verified there was no record of a current driver’s license in the personnel record.

Deficiency cited, routine inspection : 2980 Water supply, sewage and waste disposal WAC 246-337-130(2) The licensee shall ensure: (2) Tempered water between one hundred and one hundred twenty degrees

Based on interview and inspection of the facility, the agency failed to maintain hot water temperatures between 100 and 120-degrees Fahrenheit throughout the facility. Failure to provide proper water temperatures may result in disease transmission for staff and clients. 1. During the inspection of the facility, the Reviewer observed that the hot water temperatures did not meet the correct water temperature as evidenced by the following: a. The temperature of Hemlock’s shower was 80.2 degrees F. 2. During an interview with Staff C, Compliance Specialist, on 01/29/25 at 11:00 AM, they verified the below standard water temperature. each deficiency listed on the inspection report form. receipt of the list of deficiencies. Report with Noted Deficiencies by submitting a plan of identify them and refer to them as such in your POC. description of the methods to correct each deficient regulation is met. following elements: acceptable plan of correction for the specific deficiency cited; the plan of correction is effective and that specific deficiency requirements; implementing the acceptable plan of correction. is not acceptable. If a deficiency has already been was accomplished), possible recurrence of the deficiency. realistic and coinciding with the amount of time your facility immediately and monitored appropriately. Some deficiencies require bids, remodeling, replacement of equipment, etc., however, should be within a reasonable and mutually person, either by position or title ...

Deficiency cited, routine inspection : 0935 Clinical record content WAC 246-341-0640(1)(c)(iv) Each agency is responsible for the components and documentation in an individual's clinical record conte

Washington Administrative Code is not met as evidence by: Based on clinical record review, P&P review, and staff interview, it was determined the agency failed to document a diagnostic assessment statement supported by. the current and applicable American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. (DSM-5). The agency failed to document placement decision using ASAM criteria dimensions, when the assessment indicates the individual is in need of substance use disorder services. Failure to ensure that a diagnostic assessment statement includes sufficient data to determine a diagnosis supported by the (DSM-5) may result in inaccurate diagnosis as well as an inaccurate level of care recommendation for treatment services. Failure to ensure the ASAM criteria is used in making placement decisions places residents at risk of not receiving the appropriate level of care for treatment services. Reference: The ASAM Criteria, Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, American Society of Addiction Medicine, Third Edition, 2013, Page 110. “The ASAM criteria multidimensional assessment helps ensure comprehensive treatment. In the process of patient assessment, certain problems and priorities are identified as justifying admission to a particular level of care. The resolution of those problems and priorities determines when a patient can be ...

Deficiency cited, complaint investigation : WAC 246-337-075 (2)(a)(g) Resident rights.

Based on staff interview, root cause analysis review, policy and procedure review, and patient clinical document review, the agency failed to ensure patients were free from abuse and failed to ensure they had a safe environment for 4 of 4 patients reviewed (Patient #1, #2, #3, and #4). Failure to ensure patients are free from abuse and have a safe environment can lead to poor patient outcomes and create long term traumas. 1. During an interview on 04/12/22 at 1:00 PM, Staff A, Licensing and Compliance Manager, stated that patients “are supervised at all times…we do regular checks.” Staff A stated that the patients supervised at all times means that they are within eyesight- but not line of sight or one to one. Staff A stated that, “they just can’t roam around campus and do whatever they want.” Staff A stated that there are 15-minute checks at night. 2. Review of the document titled, "Facility Rules & Guidelines", undated, showed that facility rules included the following: "Residents are not allowed in other resident's bedrooms at any time; residents must be in their own bedroom at the designated 'lights out' time; residents may be asked to leave bedroom door ajar…" During an email exchange between the Investigator and Staff A on 04/28/22 at 9:53 AM, Staff A stated that these rules were provided to all patients in the handbook upon admission. 3. Review of the “Root Cause Analysis”, dated 03/07/22, showed that Patient #3 had gone into the room of Patient #1, #2 and #4 on the ...

Deficiency cited, complaint investigation : WAC 246-337-075 (3) Resident rights.

Based on staff interview and policy and procedure review, the agency failed to provide patient rights to 1 of 4 patients reviewed (Patient #3). Failure to ensure that patient rights are provided upon admission can lead to poor patient outcomes. 1. Review of the policy titled, "Individual Rights", revised 01/01/21, showed that the patient rights would be posted in a central location and would be reviewed with all patients upon admission. The procedure showed that all patients and parents or guardians are provided a copy of the rights upon admission. 2. During an email exchange between the Investigator and Staff A, Licensing and Compliance Manager, on 04/25/22 at 5:16 PM, Staff A stated they were unable to locate signed patient rights for Patient #3.

Deficiency cited, complaint investigation : WAC 246-337-065 (5)(a) Safety and Security.

Based on staff interview, the agency failed to report to the Department of Health an incident of sexual abuse for 1 or 4 patients reviewed (Patient #3). Failure to report incidents of abuse to the department within the reporting times can result in poor patient outcomes. 1. During an interview on 04/12/22 at 1:00 PM, Staff A, Licensing and Compliance Manager, stated that the alleged sexual assault incident was only reported to the Department of Children, Youth and Family (DCYF) and was not reported to DOH. Staff A was not aware that this should have been reported to the Department of Health. Plan of Correction Instructions each deficiency listed on the statement of deficiency form. receipt of the list of deficiencies. deficiencies by submitting a plan of correction (POC). Be sure as such in your POC. description of the methods to correct each deficient practice regulation is met. following elements: plan of correction for the specific deficiency cited; plan of correction is effective and that specific deficiency implementing the acceptable plan of correction. is not acceptable. If a deficiency has already been corrected, accomplished), recurrence of the deficiency. realistic and coinciding with the amount of time your facility will and monitored appropriately. Some deficiencies may require replacement of equipment, etc., may need more time to reasonable and mutually agreeable time-frame. person, either by position or title, who will be responsible please use the checklist ...

Deficiency cited, complaint investigation : WAC 246-341-0420 (13)(a), Agency policies and procedures.

Based on staff interview and policy and procedure review, the agency failed to ensure that they followed their policy to report to the department within 48 hours any critical incident that occurred to an individual for 1 of 4 patients reviewed (Patient #3). Failure to report critical incidents to the department can lead to poor patient outcomes. 1. During an interview on 04/12/22 at 1:00 PM, Staff A, Licensing and Compliance Manager, stated that the alleged sexual assault incident was only reported to the Department of Children, Youth and Family (DCYF) and was not reported to DOH. Staff A was not aware that this should have been reported to the Department of Health. 2. Review of the policy titled, “Completing and Submitting Reports”, revised 01/01/21 showed that the agency would “complete and submit reports in accordance with WAC 246-341-0420 (13).” 3. Review of the policy titled, “Reporting Critical Incidents Involving Individuals”, revised 01/01/21, showed that “serious or undesirable outcomes” must be reported to DOH by the end of the next business day. Critical Incidents included “sexual contact between clients.”

Deficiency cited, complaint investigation : WAC 246-341-0600, (3)(a) Clinical – Individual rights.

Based on staff interview and policy and procedure review, the agency failed to provide patient rights to 1 of 4 patients reviewed (Patient #3). 1. Review of the policy titled, "Individual Rights", revised 01/01/21, showed that the patient rights would be posted in a central location and would be reviewed with all patients upon admission. The procedure showed that all patients and parents or guardians are provided a copy of the rights upon admission. 2. During an email exchange between the Investigator and Staff A, Licensing and Compliance Manager, on 04/25/22 at 5:16 PM, Staff A stated they were unable to locate signed patient rights for Patient #3. OF WASHINGTON OF HEALTH review of the Plan of Correction (POC) you conducted at your facility, the Department has stated in your plan that you will implement By this, the Department is accepting your Plan of listed in your statement of deficiency report, follow-up compliance visit to verify that all that may be enforced based on the results of the with WAC 246-341-0365 and WAC 246-337-990 to pursue enforcement action for any repeat and/or statute and rules. address you have on file if you have questions cooperation and hard work during the investigation.

Deficiency cited, complaint investigation : WAC 246-337-075 (2)(a)(g) Resident rights.

Based on staff interview, root cause analysis review, policy and procedure review, and patient clinical document review, the agency failed to ensure patients were free from abuse and failed to ensure they had a safe environment for 4 of 4 patients reviewed (Patient #1, #2, #3, and #4). Failure to ensure patients are free from abuse and have a safe environment can lead to poor patient outcomes and create long term traumas. 1. During an interview on 04/12/22 at 1:00 PM, Staff A, Licensing and Compliance Manager, stated that patients “are supervised at all times…we do regular checks.” Staff A stated that the patients supervised at all times means that they are within eyesight- but not line of sight or one to one. Staff A stated that, “they just can’t roam around campus and do whatever they want.” Staff A stated that there are 15-minute checks at night. 2. Review of the document titled, "Facility Rules & Guidelines", undated, showed that facility rules included the following: "Residents are not allowed in other resident's bedrooms at any time; residents must be in their own bedroom at the designated 'lights out' time; residents may be asked to leave bedroom door ajar…" During an email exchange between the Investigator and Staff A on 04/28/22 at 9:53 AM, Staff A stated that these rules were provided to all patients in the handbook upon admission. 3. Review of the “Root Cause Analysis”, dated 03/07/22, showed that Patient #3 had gone into the room of Patient #1, #2 and #4 on the ...

Deficiency cited, complaint investigation : WAC 246-337-075 (3) Resident rights.

Based on staff interview and policy and procedure review, the agency failed to provide patient rights to 1 of 4 patients reviewed (Patient #3). Failure to ensure that patient rights are provided upon admission can lead to poor patient outcomes. 1. Review of the policy titled, "Individual Rights", revised 01/01/21, showed that the patient rights would be posted in a central location and would be reviewed with all patients upon admission. The procedure showed that all patients and parents or guardians are provided a copy of the rights upon admission. 2. During an email exchange between the Investigator and Staff A, Licensing and Compliance Manager, on 04/25/22 at 5:16 PM, Staff A stated they were unable to locate signed patient rights for Patient #3.

Deficiency cited, complaint investigation : WAC 246-337-065 (5)(a) Safety and Security.

Based on staff interview, the agency failed to report to the Department of Health an incident of sexual abuse for 1 or 4 patients reviewed (Patient #3). Failure to report incidents of abuse to the department within the reporting times can result in poor patient outcomes. 1. During an interview on 04/12/22 at 1:00 PM, Staff A, Licensing and Compliance Manager, stated that the alleged sexual assault incident was only reported to the Department of Children, Youth and Family (DCYF) and was not reported to DOH. Staff A was not aware that this should have been reported to the Department of Health. Plan of Correction Instructions each deficiency listed on the statement of deficiency form. receipt of the list of deficiencies. deficiencies by submitting a plan of correction (POC). Be sure as such in your POC. description of the methods to correct each deficient practice regulation is met. following elements: plan of correction for the specific deficiency cited; plan of correction is effective and that specific deficiency implementing the acceptable plan of correction. is not acceptable. If a deficiency has already been corrected, accomplished), recurrence of the deficiency. realistic and coinciding with the amount of time your facility will and monitored appropriately. Some deficiencies may require replacement of equipment, etc., may need more time to reasonable and mutually agreeable time-frame. person, either by position or title, who will be responsible please use the checklist ...