Observations
Based on a review of outpatient client records, the facility failed to assure counseling services are provided according to the individual treatment plan and rehabilitation plan in five out of seven charts reviewed.
Client #1 was admitted on May 22, 2024, and was still active at the time of the inspection. A treatment plan completed on August 13, 2024, indicated the client was to receive one individual session per week. During the week of August 25-31, 2024, no individual sessions were documented in the client record.
Client #2 was admitted on May 10, 2024, and was still active at the time of the inspection. A treatment plan completed on June 10, 2024, indicated the client was to receive one individual session per week. During the weeks of June 9-15, 2024 and June 16-22, 2024, no individual sessions were documented in the client record.
Client #4 was admitted on April 2, 2024, and was discharged on July 22, 2024. A treatment plan completed on April 19, 2024, indicated the client was to receive one individual session per week. During the weeks of April 29-May 26, 2024, no individual sessions were documented in the client record.
Client #6 was admitted on October 24, 2023, and was discharged on September 17, 2024. A treatment plan completed June 22, 2024, indicated the client was to receive one individual session per week. During the week of July 1-6, 2024, no individual sessions were documented in the client record.
Client #7 was admitted on April 30, 2024, and was discharged on September 17, 2024. A treatment plan completed, April 30, 2024, indicated the client was to receive one individual session per week. During the week of May 19-25, 2024, no individual sessions were documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
1. Beginning on 11/26/2024, the Plan of Correction (POC) and its requirements will be communicated to all clinical staff during Group Supervision. Each clinician will ensure that each client receives the clinical services indicated on the client's completed treatment plan. Each service received will be documented on a corresponding DAP note or group note. In the event that the client does not attend the designated service, the client's absence will be documented, and the clinician and/or assigned designee will contact the client to reschedule the missed appointment and document this contact attempt within the client's chart. Review of this requirement will be documented in the clinical group supervision record.
2. When a clinical service is not scheduled or documented within the Electronic Health Record (EHR), each clinician will ensure that an independent note is placed into the client chart explaining why there is no scheduled clinical service for the time period missed.
3. If a client's frequency of clinical services has changed, the clinician will complete an updated treatment plan reflecting the new frequency of clinical services.
4. Plan or Correction will be monitored during monthly individual supervisions with clinicians as well as random client chart audits.
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