Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation at intake, per facility policy, in four out of seven applicable records reviewed.
Client #1was admitted on February 21, 2025, and discharged on May 28, 2025. The psychosocial evaluation was due to be completed on February 21, 2025; however, it was not completed until February 28, 2025.
Client #4 was admitted on February 25, 2025, and still active at the time of the inspection. The psychosocial evaluation was due to be completed on February 25, 2025; however, it was not completed until March 31, 2025.
Client #5 was admitted on March 07, 2025, and still active at the time of the inspection. The psychosocial evaluation was due to be completed on March 07, 2025; however, it was not completed until March 10, 2025.
Client #6 was admitted on March 28, 2025, and still active at the time of the inspection. The psychosocial evaluation was due to be completed on March 28, 2025; however, it was not completed until April 01, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Evolve Addiction Recovery's policy and procedure stated that documentation of the biopsychosocial to be completed and signed on the same day of when the biopsychological was performed/completed with the client. The policy and procedure for code 709.24 in which this reflects, has been changed/updated by Evolve Addiction Recovery's Executive/Clinical Director to reflect that the documentation of the biopsychosocial to be completed and signed (by both the individual that performed the evaluation and the clinical supervisor/director) within 7 business days of when the biopsychosocial was performed/completed with the client.
The Executive/Clinical Director is responsible for ensuring this corrective action is implemented.
Date in which the corrective action will be completed is on 8/29/2025. |
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 within one business day after therapy sessions, per facility policy, in five out of seven records reviewed.
Client #2 was admitted May 07, 2025, and discharged on July 07, 2025. The record contained progress notes for group sessions occurring on May 30, 2025, June 04, 2025, June 18, 2025, and June 25, 2025, that were not completed until June 10, 2025, June 10, 2025, June 24, 2025, and July 01, 2025, respectively. Additionally, there was a progress note for a group session occurring on June 11, 2025, that was not completed at the time of the inspection.
Client #3 was admitted on My 14, 2025, and discharged June 11, 2025. The record contained a progress note for a group session occurring on May 21, 2025, that was not completed until June 09, 2025.
Client #5 was admitted on March 07, 2025, and still active at the time of the inspection. The record contained progress notes for individual sessions occurring on March 28, 2025, June 06, 2025, and June 27, 2025, that were not completed until April 14, 2025, June 12, 2025, and July 01, 2025. Additionally, the record contained progress notes for group sessions occurring on May 30, 2025, June 06, 2025, June 13, 2025, June 27, 2025, July 11, 2025, July 18, 2025, and August 01, 2025, that were not completed until June 10, 2025, June 10, 2025, June 18, 2025, July 06, 2025, July 21, 2025, July 23, 2025, and August 05, 2025, 2025, respectively.
Client #6 was admitted on March 28, 2025, and still active at the time of the inspection. The record contained a progress note for an individual session occurring on April 04, 2025, that was not completed until July 22, 2025.
Client #7 was admitted on April 08, 2025, and still active at the time of the inspection. The record contained progress notes for group sessions occurring on May 20, 2025, May 21, 2025, May 27, 2025, May 30, 2025, June 05, 2025, June 09, 2025, June 12, 2025, June 13, 2025, June 19, 2025, July 01, 2025, July 02, 2025, July 08, 2025, July 18, 2025, July 24, 2025, July 25, 2025, July 28, 2025, July 29, 2025, August 05, 2025, and August 13, 2025, that were not completed until June 09, 2025, June 09, 2025, June 09, 2025, June 10, 2025, June 10, 2025, June 12, 2025, June 17, 2025, June 18, 2025, June 26, 2025, July 09, 2025, July 09, 2025, July 11, 2025, July 23, 2025, July 31, 2025, July 31, 2025, July 31, 2025, August 04, 2025, August 08, 2025, and August 19, 2025, respectively.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Evolve Addiction Recovery's policy and procedure stated that documentation for progress notes were to be completed and signed next business day of when the therapy session was performed/completed with the client. The policy and procedure for code 709.24 in which this reflects, has been changed/updated by Evolve Addiction Recovery's Executive/Clinical Director to reflect that the documentation for progress notes are to be completed and signed by the individual that performed the therapy session within 7 business days of when the therapy session was performed/completed with the client.
The Executive/Clinical Director is responsible for ensuring this corrective action is implemented.
Date in which the corrective action will be completed is on 8/29/2025. |