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 two out of two applicable records reviewed.Client #1 was admitted on December 4, 2024, and was discharged on May 5, 2025. A treatment plan dated February 24, 2025, indicated one hour of group or individual therapy per month. There was no documentation of the client receiving group or individual therapy for the months of February 2025 and March 2025. Client #2 was admitted on December 11, 2024, and was still active at the time of the inspection. A treatment plan dated May 30, 2025 indicated one individual and one group therapy session per month. There was no documentation that the client received an individual or group therapy session in the month of May 2025. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical team meeting conducted 8/13/2025 to review treatment plans and documentation of sessions/no shows.
Clinical supervisor to follow up with counselors to ensure they are scheduling in EMR calendars, not paper, which will track appointments. Counselors are to update EMR appointments at time of scheduled appointments with case note, or no show. Counselors will review at the end of each day and update as needed. Counselors will also "check out" with supervisor at end of day prior to leaving for review. |