Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two of the seven records reviewed.
Client #5 was admitted on May 9, 2024, and was still active at the time of the inspection. There was documentation that information was disclosed to the funder, county court, probation, and a lab on May 9, 2024; however, the record did not contain documentation of informed and voluntary consent forms from the client for the disclosure of information.
Client #7 was admitted on April 16, 2024, and discharged on July 11, 2024. There was documentation that information was disclosed to the funder, probation and youth services on April 16, 2024; however, the record did not contain documentation of informed and voluntary consent forms from the client for the disclosure of the information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 30th, 2025, the Clinical Supervisor will meet with counselors and review consent forms and the importance of these forms being completed.
For client #5, counselor will complete required/needed consents by 05/09/2025.
Ongoing, during monthly chart audits, Clinical Supervisor will review that releases are in place for any external sources we may need to or are contacting. Any identification of missing releases will be emailed to the counselor to correct during the next visit with the client.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed immediately after therapy sessions, in five of seven records reviewed.
Client # 1 was admitted on October 25, 2024 and was still active at the time of the inspection. The record contained a progress note for an individual session occurring on October 25, 2024, that was not completed until October 31, 2024.
Client # 2 was admitted on October 30, 2024 and was still active at the time of the inspection. The record contained progress notes for individual sessions occurring on November 02, 2024, November 19, 2024, December 17, 2024, and January 11, 2025; that were not completed until November 06, 2024, November 25, 2024, December 20, 2024, and January 14, 2025, respectively.
Client # 3 was admitted on November 25, 2024 and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on January 21, 2025, January 27, 2025, February 3, 2025, February 25, 2025, March 17, 2025; that were not completed until January 27, 2025, February 3, 2025, February 10, 2025, and March 23, 2025. Additionally, the record contained progress notes for group sessions occurring on February 5, 2025, February 10, 2025, February 12, 2025, February 13, 2025, March 19, 2025; that were not completed until February 12, 2025, February 19, 2025, February 20, 2025, February 20, 2025, March 23, 2025, respectively.
Client # 5 was admitted on May 09, 2024 and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on October 08, 2024, November 05, 2024, January 14, 2024, and February 4, 2025; that were not completed until October 16, 2024, November 9, 2024, January 21, 2025, and February 10, 2025, respectively.
Client # 6 was admitted on June 4, 2024 and discharged August 5, 2024. The record contained progress notes for individual sessions occurring on October 07, 2024, November 11, 2024, March 17, 2025, and March 19, 2025; that were not completed until October 16, 2024, November 18, 2024, March 23, 2025 and March 25, 2025, respectively.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 13, 2024 licensing inspection.
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Plan of Correction
On April 30th, 2025 during scheduled clinical meeting, the clinical supervisor will review the completion of notes immediately after the therapy session. Additionally, the Clinical Supervisor will be reviewing the counselors' schedules to ensure that each week time is scheduled for the completion of all notes by weeks end.
Ongoing, the Division Director will run a report reflecting note completion and will follow up with Clinical Supervisor on Monday afternoon that any outstanding notes will need to be completed by Tuesday.
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