Observations
Based on a review of seven outpatient client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in two charts reviewed.
Client #1 was admitted on March 30, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, April 11, 2023, indicated 1 individual session bi-weekly and three group sessions weekly. The chart's record of service and progress notes indicated that the client only received individual sessions on April 11, 2023 and May 1, 2023. Additionally the client only received group session on June 19, 2023 and June 26, 2023 for the month of June.
Client #2 was admitted on March 31, 2023 and was discharged on June 16, 2023. The comprehensive treatment plan, dated April 14, 2023 , indicated 1 individual session bi- weekly and group weekly. The chart's record of service and progress notes indicated that the client only received individual sessions on March 31, 2023, April 14, 2023, May 5, 2023 and June 16, 2023.
Client #4 was admitted on April 4, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated April 18, 2023 , indicated 1 individual session bi-weekly and group weekly. The chart's record of service and progress notes indicated that the client only received individual session on April 5, 2023, April 8, 2023 and May 2, 2023. Additionally, the client not receive any group sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/19/2023, training was conducted at staff meeting to address clients receiving counseling services according to their treatment plan. Staff were advised that after initial assessment or intake, all clients are to be placed on a recurring group roster. Adding clients to recurring group rosters allows counselors to appropriately status client attendance as Kept, DNS (Did not Show)or CBC (Cancelled by client). All counselors will have the group recurring on their schedule to allow for groups to show on the client chart facesheet, which will allow for client attendance tracking. Additionally, staff were informed that at the conclusion of every individual session, the client should leave with another individual session scheduled. The director will review group rosters at weekly staff meeting to ensure clients are placed on the appropriate rosters. At monthly supervision, the director and the clinical team will conduct a chart audit for service compliance on 10% of the outpatient caseload. In addition, the quality and compliance team review a minimum of 5 treatment records per month which include both active and discharged charts. One of the monthly indicators that is monitored is if the frequency of sessions offered and completed is in accordance with applicable licensing and funder expectations, which includes services consistent with those identified on the treatment plan. The Quality and Compliance team meets with site leadership monthly to review key performance indicators. If an indicator falls below the 80% benchmark, areas of opportunity are identified and discussed during these meetings. |
Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy in two of four applicable outpatient client records reviewed.
Client #2 was admitted on March 31, 2023 and was discharged on June 16, 2023. The client record did not contain documentation of follow up information with the client within 7 days of discharge.
Client #6 was admitted on March 15, 2023 and was discharged on May 17, 2023. The client record did not contain documentation of follow up information with the client within 7 days of discharge.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 14, 2023 annual licensing inspection.
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Plan of Correction
The Pyramid Healthcare written policy for client discharge from the program is that all clients will be called within 7 days of the discharge date. To ensure proper completion of the 7-day follow-up calls, the director will print a discharge list for all clients discharged the week prior and present this list at weekly staff meeting. All staff will be provided with their list of clients to contact. Director will do an end-of-the-week audit on 50% of the discharge list and confirm the call logs are completed. Routine monitoring will also be conducted on a monthly basis to review whether re-engagement/follow up call is documented post-discharge. In addition, the quality and compliance team review a minimum of 5 treatment records per month which include both active and discharged charts. One of the monthly indicators that is monitored is follow-up calls post discharge. |