Pearl Youth Residence

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

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

Based on interview and document review, the facility failed to ensure that resident rights were protected in compliance with this chapter and other applicable laws. Failure to ensure the protection of patient rights and compliance with this chapter and other applicable laws may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - Respect human dignity and foster constructive self-esteem. 1. Review of the facility policy titled, “General Client Rights”, last revised 08/2022, showed that the policy intended to outline and describe the rights of patients who receive services at the facility. It showed that it was the facility’s responsibility to ensure that all patients were awarded their patient rights; that patient rights were protected; and that all staff adhered to these policies and procedures. It showed that all patients would be treated with respect, dignity and privacy. 2. Review of the facility policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed that patients could make verbal and written complaints. It showed the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. It showed if a patient complained, those complaints would be handled by that staff member promptly, dependably, and courteously. 3. Review of a ...

Deficiency cited, complaint investigation : WAC 246-337-065 Safety and security.

Based on interview and document review the facility failed to ensure the protection of residents safety and security. Failure to ensure that the protection of residents safety and security may lead to a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the Department of Health, Law Enforcement and other entities as required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant and intentional disregard for the safety or well-being of others. f. The policy defined “sexual contact” as an “intentional touching of the lips, genitalia, thigh, breast, buttocks, or clothing or clothing covering those areas of a person done for the purpose to abuse, humiliate, harass, degrade, arouse, or gratify the sexual desire of any person.” g. It showed that sexual ...

Deficiency cited, complaint investigation : WAC 246-337-045 Governance and administration.

Based on interview and record review, the facility governing body failed to ensure that organizational guidance and oversight ensuring that staff provide safe and adequate resident care was provided. Failure to ensure that organizational guidance and oversight is provided by the facility’s governing body may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the program director [Staff D] would ensure that a written internal quality management plan and process was developed and maintained, to include ensuring the supervision and training of clinical staff. 2. Review of the facility policy titled, “Program Structure”, last revised 02/2021, showed that the milieu manager [Staff B] was responsible for providing oversight of services to ensure a safe environment and was responsible for the supervision of assigned staff. 3. Review of a facility policy titled, “Clinical Supervision”, last revised 07/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision to all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with ...

Deficiency cited, complaint investigation : WAC 246-337-048 Quality improvement program.

Based on observation, interview and record review, the facility failed to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to patients, including collecting in assessing data related to resident grievances and unanticipated resident or facility outcomes. Failure to ensure ongoing efforts to ensure the quality of care provided to patient may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. 1. Review of a policy titled, “Quality Management Process”, last revised 06/2022, showed the following: a. Facility staff would establish and maintain a quality management processes to promote the quality of care for all patients. b. Quality improvement staff and program managers would be involved in this process. c. Facility staff would continuously collect, maintain and use information to correct deficiencies and improve services, including critical incident reports and grievances. 2. Review of a policy titled, “Resident Rights- Grievances”, last revised 02/2021, showed the following: a. That the facility pledged to uphold the rights of patients to express grievances and ensure grievances could be made without fear of interference, coercion, or reprisal. b. During the investigation the program director would meet with the grievant, involved staff, and others to investigate and ...

Deficiency cited, complaint investigation : WAC 246-341-0600 Individual rights.

Based on interview, observation, and document review the facility failed to protect and promote individual patient rights; comply with patient rights listed in RCW 71.05; ensure that patients were treated with respect, dignity, and privacy; and ensure that patients were free from abuse, sexual harassment, and exploitation. Failure to ensure that patient rights are protected and that patients are treated with dignity and respect, may cause a systemic failure to ensure a safe and supportive treatment environment; exacerbate patients’ mental health conditions; or lead to instances of patient abuse or neglect. Item #1 - The right to be free of sexual abuse, harassment, and exploitation. 1. Review of a policy titled, “General Client Rights”, last revised 08/2022, showed the following: a. Patients have the right to be treated with respect, dignity, and privacy. b. Patients have the right to be free of sexual harassment; be free of exploitation; and have all clinical and personal information treated in accordance with state and federal confidentiality regulations. 2. Review of a policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy required adherence to safe, ethical, and legal standards for employee conduct. b. That “no employee or other person has the authority to commit or fail to report such conduct”. c. That “when abuse or sexual misconduct is reasonably suspected or is reported by an alleged victim an investigation ...

Deficiency cited, complaint investigation : WAC 246-341-0410 Agency administration—Administrator key responsibilities.

Based on document review and interviews, the agency administrator and their designees failed to ensure that all applicable rules, policies, and ethical standards were adhered to; that administrative, personnel, and clinical policies and procedures were complied with; and that there were continuous efforts to improve the quality of care for patients. Failure to follow all applicable rules, policies, and ethical standards, and put forth continuous efforts to improve the quality of care for all patients may lead to disorganization and mismanagement of staff; increased risks of adverse events exacerbating patients mental health conditions; and the compromising of patient safety and the quality of care. Item #1 - Adherence to administrative, personnel and clinical policies. 1. Review of the facility policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 03/2023, showed the following: a. The policy would ensure adherence to safe, ethical, and legal standards for employee conduct. b. When abuse or sexual misconduct was reasonably suspected or reported by an alleged victim, an investigation would occur. c. That the investigative process would include reporting to the required by law and within mandated timelines. d. If the alleged wrongdoer was a facility staff, human resources (HR) would also receive the report immediately. e. The policy defined “abuse” as physical, sexual, emotional or psychological actions that influenced another person, and included the blatant ...

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

Based on interview and record review, the facility failed to develop, implement and maintain policies and procedures that address all of the applicable licensing and certification requirements. Failure to ensure that policies and procedures are developed, maintained and implemented may lead to ineffective treatment, misunderstandings, and potential harm to patients due to errors and lack of competency among staff. 1. Review of the facility policy titled, “Critical Incidents”, last revised 3/2023, showed a critical incident was defined as a negative event which was not desired or anticipated and that involved facility staff and patients. It showed that “allegations of abuse, neglect, fraud or exploitation” was listed as a critical incident. It showed that the facility would report any critical incident to the DOH within 48-hours or one business day; that the facility would report critical incidents to “other appropriate agencies” by the end of the next business day of the incident occurring. 2. Review of a policy titled, “Abuse and Sexual Misconduct Prevention”, last revised 3/2023, showed that “when abuse or sexual misconduct is reasonably suspected or is reported by an alleged victim an investigation will occur.” It showed that the investigative process would include reporting to the required by law within mandated timelines. It showed that if the alleged wrongdoer was a facility staff, HR would also receive the report immediately. 3. Review of facility documentation that ...

Deficiency cited, complaint investigation : WAC 246-341-0515 Personnel—Agency staff requirements.

Based on record review and interviews, the facility failed to ensure that staff providing clinical services were appropriately credentialed for the services they were providing, and that all staff providing clinical services received supervision. Failure to ensure that staff providing clinical services are appropriately credentialed and receive clinical supervision may lead to inappropriate treatment interventions and outcomes; a worsening in the patient’s condition; a compromise of safety protocols and ethical standards; and place vulnerable patients at risk of harm. 1. Review of a facility policy titled, “Clinical Supervision”, last revised 7/2023, showed: a. Qualified mental health professionals would provide regular clinical supervision all employees, volunteers, interns, and trainees providing direct treatment services. b. Clinical supervision would cover aspects of assessment, treatment planning, and service delivery. c. Clinical supervision would ensure compliance with professional standards. d. Case specific clinical supervision or consultation would be documented in the patient record. e. Supervision notes could be completed by either the clinical supervisor or staff member with approval from the clinical supervisor. 2. Review of a facility document titled, “Job Description”, dated 12/07/22, for Staff A, Behavioral Health Technician (BHT) showed: a. Duties included providing direct patient care services such as implementing individualized care specific to patient ...

Deficiency cited, complaint investigation : WAC 246-341-0640 Individual service record content.

Based on interview and document review, the facility failed to ensure that the individual service record contained all required components and documentation. Failure to ensure that the individual service record is complete and contains all required documentation may lead to vulnerable patients continuing to be subjected to harmful situations; legal complications for patient receiving court ordered treatment; or, causing patients to feel a diminished trust in the services that are being provided if treatment plans or mandated reporting requirements aren’t followed. In addition, failure to ensure that patient encounters are documented in such a manner that clinical staff can rely on their independent recollection of the date; the time; the duration; and clinically significant behaviors demonstrated by the patient, may also lead to undesirable patient outcomes, including: diminished standards of patient care; a failure to capture clinically relevant details of patient encounters; an inability to ensure the quality of services provided; unreliability of clinical records; and could call in to question the ethical integrity of the clinician, or the facility promoting such practice. Item #1 - Treatment Plans 1. Review of four clinical records showed that 2 of 4 (Patients #1, #2 and #3) individual service records did not contain a start date and an end date, or applicable DSM-V diagnostic criteria, codes or descriptors. Records reviewed showed that the individual service plan ...

Deficiency cited, complaint investigation : WAC 246-341-1133 Evaluation and treatment services—Service standards.

Based on interviews and records review, the facility failed to ensure that discipline was fair, reasonable and consistent, and that seclusion was not used as a punitive measure. Failure to ensure that the facility exercised fair, reasonable, and consistent disciplinary practices, including not utilizing seclusion as a punitive measure, may lead to physical and psychological harm; constitutes a violation of patient rights; and could create reluctance to engage in treatment or seek help in the future. 1. Review of a facility document titled, “Resident Handbook”, dated 02/2022, showed that “Off Programming” was defined as “ Your MDT [multidisciplinary team] has determined you are unsafe to be in the day use area. You must remain in room (or designated area) for a certain amount of time, usually for 24 hours. All your needs must be met by your contact, and you must be escorted to bathroom. You will be required to knock for staff and wait for them to access your needs.” 2. Review of the clinical record for Patient #4, showed: a. Patient #4 was admitted to the facility on 06/06/23 as a voluntary patient. b. The record contained a milieu progress note dated 08/13/23, that showed that the patient informed staff that they wanted to demand discharge. It showed they later on the same day they asked for their demand not to be processed. c. The document showed “staff let [Patient #4] know that even though it [discharge] wasn’t put though it still counts as asking for discharge and [they] ...

Deficiency cited, routine inspection : 0480 Governance and administration WAC 246-337-045(1)(d)(iii) The licensee must establish a governing body with responsibility for operating and maintaining the

Based on the agency’s Policies and Procedure (P&P) review, clinical documentation review, agency internal processes and interview, it was determined the agency failed to maintain the monitoring of the agency’s compliance with the rules in this chapter, and other state and federal rules and laws that govern agency licensing and certification requirements. Failure to meet the standard of the WAC places clients at risk of not receiving the minimum standard of care. Failure of the Administrator or their designee to maintain monitoring of the agency’s Quality Management Plan (QMP) according to WAC may jeopardize the RTF and BHA licenses, may lead to investigation and fines, compromised service processes and potentially places staff at risk for liability claims. 1. The agency organizational P&Ps across all sites and services indicate all WAC, RCW, State and Federal regulations will be implemented, monitored, ensured compliance and maintained for WA State Residential Treatment Facility (RTF) 246-337 (to include Food Code 246-215) and Behavioral Health Agency (BHA) 246-341 licensure standards. • It is important to note that the agency has a streamlined process across all site and services/programs yet has displayed inconsistencies of monitoring and ensuring compliance. Forms need to be reviewed for WAC updates to reflect the most current language of 5/25/2021 – example: Individual Rights have the current WAC language, yet the form date is 5/4/2020. Clinical charts are reviewed ...