Observations
Based on a review of outpatient client records, the facility failed to ensure that counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented: Individual counseling, at least twice weekly.
Client #1 was admitted on December 5, 2025, and discharged on December 28, 2025. A review of the client record indicated that only one individual session was documented during the week of December 21-27, 2025.
This finding was reviewed with facility staff during the complaint investigation process.
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Plan of Correction
To prevent recurrence of this deficiency, the following corrective actions will be implemented:
Scheduling Protocol Enhancement:
- All outpatient clients will have individual counseling sessions scheduled at the time of admission to ensure a minimum of two sessions per week.
- Schedules will be entered into the electronic health record (EHR) and reviewed weekly by the Lead Therapist or Clinical Supervisor.
Documentation Accountability:
- Therapists will be required to complete and sign individual counseling notes within 24 hours of each session.
- The EHR will be utilized to flag missing or incomplete documentation related to required services.
Clinical Oversight and Audits:
- The Clinical Director or designee will conduct weekly chart audits to verify:
- - Frequency of individual counseling sessions
- - Timeliness and completeness of documentation
- - Any identified deficiencies will be addressed immediately with the assigned clinician.
Staff Training and Education:
- All clinical staff will receive refresher training on: 1/28/2026
- - Program service requirements
- - Documentation standards
- - Regulatory expectations for outpatient services
- - Training will be documented and maintained in personnel files.
Monitoring and Ongoing Compliance:
- Weekly chart audits will continue for a minimum of 90 days to ensure sustained compliance.
- Results of audits will be reviewed during clinical team meetings.
- Corrective action plans or additional supervision will be provided to staff as needed.
Responsible Party:
- Clinical Director / Lead Therapist
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