Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed with 72 hours after therapy sessions, per facility policy, in seven out of seven records reviewed.
Client # 1 was admitted on July 23, 2025, and still active at the time of the inspection. The record contained a progress note for an individual session occurring on July 25, 2025, that was not completed until August 4, 2025.
Client #2 was admitted on July 22, 2025, and still active at the time of the inspection. The record contained a progress note for an individual session occurring on July 25, 2025, that was not completed until August 3, 2025. Additionally, the record contained progress notes for group sessions occurring on July 31, 2025, August 01, 2025, August 02, 2025, August 03, 2025, August 04, 2025, August 06, 2025, August 08, 2025, August 12, 2025, August 13, 2025, August 14, 2025, and August 15, 2025, that were not completed until August 10, 2025, August 10, 2025, August 10, 2025, August 10, 2025, August 11, 2025, August 19, 2025, August 11, 2025, August 19, 2025, August 19, 2025, August 19, 2025, August 18, 2025, August 19, 2025, and August 19, 2025, respectively.
Client #3 was admitted on July 16, 2025, and discharged on August 12, 2025. The record contained a progress note for an individual session occurring on August 10, 2025, that was not completed until August 16, 2025. Additionally, the record contained progress notes for group sessions occurring on July 16, 2025, July 17, 2025, July 21, 2025, July 23, 2025, July 24, 2025, July 25, 2025, July 28, 2025, July 31, 2025, August 01, 2025, August 02, 2025, August 03, 2025, August 04, 2025, and August 06, 2025, that were not completed until July 30, 2025, July 31, 2025, July 27, 2025, July 30, 2025, July 30, 2025, July 31, 2025, August 10, 2025, August 10, 2025, August 10, 2025, August 10, 2025, August 10, 2025, August 10, 2025, and August 11, 2025, respectively.
Client #4 was admitted on October 27, 2024, and discharged on December 11, 2024. The record contained a progress note for an individual session occurring on October 30, 2024, that was not completed until November 04, 2024. Additionally, the record contained progress notes for group sessions occurring on October 29, 2024, October 30, 2024, October 31, 2024, November 01, 2024, November 02, 2024, November 03, 2024, November 06, 2024, November 07, 2024, November 08, 2024, November 09, 2024, November 10, 2024, November 12, 2024, November 13, 2024, November 14, 2024, November 15, 2024, November 18, 2024, November 20, 2024, November 21, 2024, November 22, 2024, November 27, 2024, November 29, 2024, December 01, 2024, December 03, 2024, December 04, 2024, December 05, 2024, December 06, 2024, December 07, 2024, December 08, 2024, and December 09, 2024, that were not completed until November 05, 2024, November 21, 2024, November 21, 2024, November 21, 2024, November 16, 2024, November 16, 2024, November 20, 2024, December 16, 2024, December 16, 2024, November 16, 2024, November 16, 2024, November 20, 2024, December 16, 2024, December 16, 2024, November 16, 2024, November 16, 2024, November 20, 2024, November 20, 2024, December 16, 2024, December 16, 2024, November 24, 2024, December 16, 2024, December 16, 2024, December 16, 2024, December 16, 2024, December 16, 2024, December 15, 2025, December 08, 2024, December 16, 2024, December 16, 2024, December 16, 2024, December 15, 2024, December 15, 2024, and December 15, 2024, respectively.
Client #5 was admitted on October 15, 2024, and discharged on November 14, 2024. The record contained progress notes for group sessions occurring on October 21, 2024, October 23, 2024, October 23, 2024, October 25, 2024, October 27, 2024, October 28, 2024, October 30, 2024, October 31, 2024, November 02, 2024, November 03, 2024, November 06, 2024, November 07, 2024, November 08, 2024, November 09, 2024, November 10, 2024, November 12, 2024, November 13, 2024, and November 14, 2024, that were not completed until November 16, 2024, November 15, 2024, October 30, 2024, November 16, 2024, November 16, 2024, November 02, 2024, November 21, 2024, November 05, 2025, November 21, 2024, November 16, 2024, November 16, 2024, November 20, 2024, December 16, 2024, December 16, 2024, November 16, 2024, November 16, 2024, November 20, 2024, November 20, 2024, and December 20, 2024, respectively.
Client #6 was admitted on November 21, 2024, and discharged on December 21, 2024. The record contained a progress note for an individual session occurring on December 14, 2024, that was not completed until December 18, 2024. Additionally, the record contained progress notes for group sessions occurring on November 21, 2024, November 22, 2024, November 22, 2024, November 27, 2024, November 27, 2024, November 29, 2024, November 29, 2024, December 01, 2024, December 04, 2024, December 05, 2024, December 06, 2024, December 07, 2024, December 08, 2024, December 09, 2024, December 11, 2024, December 12, 2024, December 13, 2024, December 14, 2024, December 20, 2024, and December 21, 2024, that were not completed until November 26, 2024, November 28, 2024, December 16, 2024, December 16, 2024, December 04, 2024, December 16, 2024, December 16, 2024, December 15, 2024, December 16, 2024, December 16, 2024, December 16, 2024, December 15, 2024, December 15, 2024, December 15, 2024, December 17, 2024, December 17, 2024, December 19, 2024, December 19, 2024, December 25, 2024 and December 26, 2024, respectively.
Client #7 was admitted on February 01, 2025, and discharged March 03, 2025. The record contained progress notes for group sessions occurring on February 03, 2025, February 06, 2025, February 07, 2025, February 08, 2025, February 09, 2025, February 10, 2025, February 12, 2025, February 17, 2025, February 18, 2025, February 19, 2025, February 20, 2025, February 21, 2025, February 22, 2025, February 23, 2025, February 24, 2025, February 26, 2025, February 27, 2025, February 28, 2025, and March 01, 2025, that were not completed until, February 13, 2025, February 16, 2025, February 16, 2025, February 16, 2025, February 25, 2025, February 16, 2025, February 20, 2025, March 06, 2025, February 25, 2025, March 09, 2025, February 25, 2025, March 06, 2025, March 06, 2025, March 06, 2025, March 06, 2025, March 03, 2025, March 06, 2025, March 06, 2025, and March 06, 2025, respectively.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In a Clinical Team meeting on 9/16/2025, Clinical Director/Executive Director reviewed the internal policy of progress notes and other client-related documentation needing to be entered within 72 hours of the service being delivered. Clinical Team was informed that Clinical Director/Executive Director will be doing random, routine chart audits on a weekly basis. 3 charts will be reviewed on Mondays, beginning 9/16/2025. Services and documentation from the previous week will be scrutinized, to ensure documentation is being entered within 72 hours from when the services was delivered. If it is not, Clinicians will be counseled on this and a game plan for determining how to be more timely will be discussed. If it continues to be an issue, Clinician will be placed on a Performance Improvement Plan. |