Observations
Based on a review of client records, the facility failed to assure that counseling sessions were provided according to the individual treatment and rehabilitation plan in four of six applicable client records reviewed.Client #1 was admitted on December 23, 2024 and was still active at the time of inspection. The individual treatment plan, completed on December 30, 2024, and treatment plan updates, completed on January 29, 2025, February 27, 2025 and March 27, 2025, indicated the client was to receive one group therapy session per week. There were no entries in the client's record of service and no progress notes indicating the client had received any group sessions from admission through to the date of the inspection.Client #2 was admitted on December 10, 2024 and was still active at the time of inspection. The individual treatment plan, completed on December 10, 2024, indicated the client was to receive one group therapy session per week. There were no entries in the client's record of service and no progress notes indicating the client had received any group sessions from admission through to the date of the inspection.Client #6 was admitted on November 11, 2024 and was discharged on December 27, 2024. The individual treatment plan, completed on November 11, 2024, indicated the client was to receive one group therapy session per week. There were no entries in the client's record of service and no progress notes indicating the client had received any group sessions during the entire treatment episode.Client #7 was admitted on June 13, 2022 and was discharged on December 20, 2024. The treatment plan updates, completed on July 22, 2024, September 20, 2024 and November 20, 2024, indicated the client was to receive one group therapy session per week. There were no entries in the client's record of service and no progress notes indicating the client had received any group sessions during the entire treatment episode.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
709.92(c) LICENSURE
Treatment and rehabilitation services:
709.92. Treatment and rehabilitation services. (c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
To comply with 709.92. (c) Treatment and rehabilitation services, the following measures have been put in place to ensure that counseling services are provided according to the individual treatment and rehabilitation plan.
Clinical Counselors will ensure prior to adding psychotherapy sessions to an individual treatment and rehabilitation plan they have fully discussed the importance of attending the agreed upon sessions.
Clinical Counselors will enroll Clients in group therapy sessions to ensure that group facilitators are aware when an enrolled Member fails to attend.
Clinical Supervisors will ensure that frequency of individual and group sessions are added to the DA tracker to monitor treatment scheduling compliance based on the proposed treatment frequency. The clinical supervisor will monitor the DA Tracker weekly to ensure compliance of treatment frequency.
Clinical Counselors who fail to schedule and enroll according to the proposed treatment frequency will be reminded immediately of the need to enroll and schedule appointments as outlined in the approved treatment and rehabilitation plan.
Members who are scheduled according to the proposed treatment frequency and fail to attend the scheduled treatment session will receive follow-up to identify the causal factor(s) for the missed appointment and to reschedule the missed appointment. If the member continues to miss scheduled appointments despite efforts to encourage full treatment participation, an addendum to the treatment and rehabilitation plan will be made to align with the Members current ability to actively participate in treatment.
On-going Monitoring:
Supervisors will monitor treatment and rehabilitation plan (treatment frequency) weekly using the DA tracker to identify scheduling and participation compliance with Treatment and Rehabilitation Plan identified treatment frequency.
The Site Director will be responsible for weekly monitoring of the Clinical Supervisors compliance with tracking DA services and to ensure that quality services are being provided based on the level of care, treatment frequency, and treatment outlined in the treatment and rehabilitation plan.
The Site Director will be responsible for reporting on the findings of the DA Tracker in monthly site meetings. Aggregate findings will be reported to identify gaps in care and to identify if additional training is needed on a site level or individual level.
Completion Date:
05/21/2025
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in two of four applicable client records reviewed.Client #6 was admitted on November 11, 2024 and was discharged on December 27, 2024. There was no documentation of follow-up information in the record as of the date of the inspection.Client #7 was admitted on June 13, 2022 and was discharged on December 20, 2024. There was no documentation of follow-up information in the record as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
In an effort to comply with 709.93(a)(11) Follow-Up information. The following corrective action plan has been revised to close the identified care caps. This revised process was reviewed with the treatment team and discharge department during the all staff meeting on Friday, May 23, 2025.
Prior to considering and completing an admin discharge for a member that is non-compliant, four official attempts must be made to reengage the member in treatment within 30 days from the last date of service and must begin within 30 minutes of the first missed appointment. These follow-up attempts and outcomes must be documented in the Member's clinical chart on the follow-up to care form.
Non-compliance and follow-up to care will be tracked by the clinical supervisor, with the understanding that our primary goal is to reengage the member in treatment.
Monitoring On-going
Discharge members are identified on the DA Post-Discharge Tracker and is the responsibility of the Clinical Supervisor to ensure compliance with 709.93 (a) (11). Clinical Supervisor are responsible for knowing when a member has missed scheduled appointments and must monitor efforts of the primary counselor to reengage the Member.
The Site Director is responsible for monitoring this process and reporting the final results to the BH Leadership Team during monthly meetings. Moving forward, the Site Director will monitor compliance weekly and consult with the Clinical Supervisor to ensure follow-up to care are meeting compliance prior to the monthly report.
The AD Manager will monitor and report on Follow-up to Care Compliance during the Monthly Site Meeting based on Key Performance Indicators in the EHR system with comparison to manual tracking.
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