Observations
Based on a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in five of six applicable client records reviewed.
Client #9 was admitted on March 27, 2024 and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on March 28, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the record for the weeks of April 7, 2024 through April 13, 2024, April 14, 2024 through April 20, 2024, June 6, 2024 through June 22, 2024, July 21, 2024 through July 27, 2024, August 4, 2024 through August 10, 2024, August 11, 2024 through August 17, 2024, August 18, 2024 through August 24, 2024, September 8, 2024 through September 14, 2024 and September 22, 2024 through September 28, 2024.
Client #10 was admitted on June 6, 2024 and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on June 11, 2024, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions documented in the record for the months of July 2024, September 2024, October 2024, November 2024, December 2024 and January 2025.
Client #11 was admitted on March 5, 2024 and was discharged on July 15, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on March 5, 2024, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions documented in the record for the months of March 2024, May 2024 and June 2024.
Client #13 was admitted on May 6, 2024 and was discharged on January 22, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on March 4, 2024, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions documented in the record for the months of June 2024, July 2024, September 2024, October 2024, and November 2024.
Client #14 was admitted on September 20, 2024 and was discharged on February 10, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on June 11, 2024, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions documented in the record for the months of October 2024, November 2024 and December 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During supervision the team members were re-educated on the proper documentation protocols. The Program Manager has added this to the audit checklist and will monitor during monthly chart audit completion. Program Manager will adress issues of noncompliance during individual supervision. |