Observations
Based on a review of client records, the facility failed to document familiarization of the fee schedule to the clients during intake procedures in seven of seven records.
There was no documentation of client familiarization of the fee schedule in the record for clients #1-7.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
We acknowledge that the fee schedule was not documented in all charts. Upon notification of this requirement, we immediately created a form indicating our fee schedule for signature by all clients upon admission to the program. The Admissions Director and Project Director will ensure this is done for all admissions into the program, and will ensure all current and future clients are compliant. |
Observations
Based on a review of client records, the facility failed to ensure the clients received counseling services according to their individual treatment plan in three of seven applicable records.
Client #1 was admitted on April 6, 2023, and discharged on July 18, 2023. The initial treatment plan and all updates indicated that the client was to have one individual therapy session per week. There was no documented individual session or noted cancelation for weeks of April 16-22, 2023, May 7-13, 2023, June 4-10, 2023, June 6-11, 2023, and July 2-8, 2023.
Client #2 was admitted on April 25, 2023, and discharged on October 19, 2023. The initial treatment plan and all updates indicated that the client was to have one individual therapy session per week. There was no documented individual session or noted cancelation for weeks of June 18-24, 2023, July 23-29, 2023, and August 13-19, 2023.
Client #4 was admitted on June 27, 2023, and discharged on September 9, 2023. The initial treatment plan and all updates indicated that the client was to have one individual therapy session per week. There was no documented individual session or noted cancelation for weeks of July 23-29, 2023, and August 13-19, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
We acknowledge that 3 clients did not have documented individual sessions every week. This program is dedicated to ensuring that all clients receive an individual session every week. Our Project Director reviewed this requirement again with all therapists during the bi-weekly clinical meeting. All therapists were instructed to document all individual therapy sessions, to include any cancellations. The Admissions Director and/or Project Director will review charts weekly and ensure all sessions are documented properly. |