Newport Academy – Seattle

Deficiency cited, routine inspection : 0705 Personnel-Agency record requirements WAC 246-341-0510(1)(c)(v) A behavioral health agency must maintain a personnel record for each person employed by the

Based on interview and personnel record review, the agency failed to ensure all staff had initial violence prevention training in the personnel record. Failure to ensure timely training may result in client harm. 1. Review of the personnel record for Staff A, Mental Health Clinical Supervisor, and Staff B, Administrative Assistant, showed that there was no initial violence prevention training in their personnel file. 2. During an interview with Staff E, Human Resources (HR) Generalist, on 12/03/24 at 12:58 PM, they stated, “I don’t see one in their first 90 days.”

Deficiency cited, routine inspection : 0715 Personnel-Agency record requirements WAC 246-341-0510(1)(d)(i) A behavioral health agency must maintain a personnel record for each person employed by the

Based on interview and personnel record review, the agency failed to ensure all staff had ongoing training in the personnel record. Failure to ensure ongoing training may result in client harm. 1. Review of the personnel record for Staff B, Administrative Assistant, showed that there were no annual cultural competency trainings in their personnel file. 2. During an interview with Staff E, HR Generalist, on 12/03/24 at 11:45 AM, they stated, “I don’t see any cultural competency trainings in the file.”

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. receipt of the list of deficiencies. 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 ...

Deficiency cited, routine inspection : 0615 Management of human resources WAC 246-337-050(4) (4) Staff must be trained, authorized, and where applicable credentialed to perform assigned job responsib

Based on interview and personnel record review, the agency failed to ensure all staff had initial violence prevention training in the personnel record. Failure to ensure timely training may result in client harm. 1. Review of the personnel record for Staff A, Mental Health Clinical Supervisor, and Staff B, Administrative Assistant, showed that there was no initial violence prevention training in their personnel file. 2. During an interview with Staff E, Human Resources (HR) Generalist, on 12/03/24 at 12:58 PM, they stated, “I don’t see one in their first 90 days.”

Deficiency cited, routine inspection : 0620 Management of human resources WAC 246-337-050(5)(a) (5) The licensee must document that staff receive the following training as applicable: (a) Initial ori

Based on interview and personnel record review, the agency failed to ensure all staff had ongoing training in the personnel record. Failure to ensure ongoing training may result in client harm. 1. Review of the personnel record for Staff B, Administrative Assistant, showed that there were no annual cultural competency trainings in their personnel file. 2. During an interview with Staff E, HR Generalist, on 12/03/24 at 11:45 AM, they stated, “I don’t see any cultural competency trainings in the file.”

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 staff had a current driver’s license in the personnel record. Failure to ensure a current driver’s license in the personnel file can lead to missed staff responsibilities and result in client harm. 1. Review of the personnel record for Staff B, Administrative Assistant, showed that there was no current driver’s license in their personnel file. 2. During an interview with Staff E, HR Generalist, on 12/03/24 at 12:52 PM, they stated, “I don’t have that.”

Deficiency cited, routine inspection : 0810 Management of human resources WAC 246-337-050(7)(j) (7) The licensee shall have written documentation for each staff member including: (j) Initial and ongo

Based on interview and personnel record review, the agency failed to ensure all staff had an initial and ongoing tuberculosis screening in the personnel file. Failure to ensure staff had an initial and ongoing tuberculosis screening may result in staff/client harm. 1. Review of the personnel record for Staff B, Administrative Assistant, showed that there was no tuberculosis screening in their personnel file. 2. During an interview with Staff E, HR Generalist, on 12/03/24 at 12:55 PM, they stated, “It is not in the file.” 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, who will be please use the checklist below to prevent delays. each deficiency listed? completion date of when ...