Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in one of seven records reviewed.
Client # 4 was admitted on March 12, 2025, and was still active at the time of the complaint investigation. The individual treatment plan, dated March 12, 2025, indicated one individual session per week. The last individual progress note was dated March 19, 2025. There was no documentation of individual sessions for the weeks of 3/24/25, 3/31/25, and 4/7/25.
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Plan of Correction
Client chart was reviewed by SUD Program Director for reported discrepancy on 4/16/25. Client had missed three weekly individual sessions and counselor failed to document missed sessions/and follow up calls. Effective immediately 4/17/2025 intake scheduler will document attempts to contact the client to reschedule the missed appointments. Effective 4/17/25, Counselor will immediately document missed appointment and attempt to follow up. Policy has also been updated to state treatment plan will be completed by the fourth completed session vs in 30-days. SUD Program Director will ensure these procedures are followed on a weekly bases by auditing charts weekly. |