Multiple critical and non-critical violations were cited including cross contamination from equipment, raw animal foods stored below cooked & ready-to-eat foods., unclean surfaces and equipment, similar to the previous inspection.
Multiple violations were cited by the Larimer County Department of Health including cross contamination from equipment, improper cooling of raw meat stored below cooked and ready-to-eat foods, unclean equipment, surfaces, utensils, etc.
The complainant made multiple allegations to the Michigan Dept. of Licensing and Regulatory Affairs about rampant alcohol use by staff and clients, sexual activity between clients and staff, loud music and smoking throughout the facility, a general lack of security and program structure. Additionally, the complainant alleged that money held on account for the client was withheld on discharge. Serenity point denied knowledge of the majority of allegations, pointing to policies and procedures in place, but was cited for failing to return personal funds to the client in a timely manner. The agency was unable to substantiate all claims.
The complainant alleged that her son was not allowed to take his medication for bipolar disorder and that he acquired a strep throat infection left untreated while under the care of Serenity Point. In response, Serenity Point claimed the client was informed that the center was not equipped to treat clients with dual diagnosis on admission and denied knowledge of his illness or symptoms of sore throat. No violations were cited.
A violation of client abuse was substantiated. The surveyor was dismayed that Best Drug Rehab did not come clean about the incident until pressed for video footage of the assault.
The client made multiple allegations in this complaint including not being advised of Recipient's Rights, or a rights program contact, and being required to submit to random drug testing without a chain of command to secure samples. As a result of this inspection, a recommendation was made for A Forever Recovery to provide Recipient's Rights brochures to each client with a rights program contact. Additionally, the program was required to add language to their policies and procedures on securing all drug screens collected.
Violations substantiated: Physical facilities inadequate for the type of service provided, no annual performance evaluations of staff members, no program director on-site, failure to provide adequate job training to staff members, failure to cooperate with state surveyor inspections, failure to comply with recipient rights regulations, failure to inform clients of the risks and possible side effects of discontinuing prescription medications, violating clients rights to be free from work the facility would otherwise employ someone else to do, accepting clients ineligible for admission, e.g., suicidal, inadequately informing clients about the general nature and objectives of the program, e.g., treatment location, or, the rules of the program, lack of appropriate medical evaluation, assessment and care, non-compliance with client activity regulations, and deviation by the program from the plan of operation for which the facility was originally licensed (10 beds) which adversely affects the character, quality and scope of services provided. Additionally, a program evaluation revealed that 45% of clients leave the program against medical advice.
Complaint allegations included heat not working properly, a ruptured water pipe and clients forced to clean kitchen and mold. Violation substantiated: Displayed Right of Recipients poster had inaccurate rights advisor's name and phone number.
Complaint allegations include misdiagnosis of acne and antibiotic treatment for actual diagnosis scabies, double billing client and insurance for detox without refund to client, and improper staffing. Violations substantiated: Not in compliance with requirements for data about relapse rates after program completion, or an annual evaluation progress report with measurable goals and objectives per R325.14113.
Complaints: Raw chicken, plumbing issues