Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information in two of seven client records reviewed.
Client #2 was admitted on February 12, 2026 and was still active at the time of the inspection. There was evidence of disclosures to the funding source since the start of the treatment episode; however, there was no valid consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client #5 was admitted on December 4, 2025 and was discharged on April 9, 2026. There was evidence of disclosures to the funding source since the start of the treatment episode; however, there was no valid consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.28 (c) and avoid further infractions, the primary counselor will notify Client #2 during their next scheduled individual counseling or group therapy session, whichever comes first, of the need to complete the consent form package applicable to their care and needs in the drug and alcohol treatment program. The consent shall include: (1) Name of the person, agency or organization to whom disclosure is made. (2) Specific information disclosed. (3) Purpose of disclosure. (4) Dated signature of client to ensure that the next claim submitted to the funding source is released in accordance with 709.28 (c).
Counselor will ensure that the updated consent form(s) align with the current treatment episode and is fully executed with (1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client,
prior to the start of their scheduled session.
Clinical supervisor will review the EHR within 30-minutes of the next scheduled session for Client #2 to ensure the consent form(s) were updated and meets standard 709.28 (c) prior to the end of the scheduled session.
Additionally, it was discovered during the completion of a root cause analysis of this infraction, that additional targeted training is needed during orientation for new hires. As a result, mock exercises have been added to the orientation training targeting Consents to release information at time of intake and program transfer (episode change). Testing for Consent to release has also been added to new hire orientation which includes but is not limited to appropriate information for the following areas:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian
On August 15, 2026, a training/meeting will be conducted with all registration assistant staff to review the correct process of completing consent to release information based on regulations. This training will include the mock exercises and testing of the existing registration assistants across all locations. This training will also include the need to complete new consent forms whenever a program transfer occurs.
On August 28,2026, an all-staff meeting will take place which will include counselors, registration assistants, and clinical supervisors, to review Standard 709.28 (c) and the proper procedures for completion of consent to release information, along with the need to complete new consent forms whenever a program transfer occurs.
Monitoring On-Going
Monitoring: Clinical supervisors and coordinators will do daily review of intakes to ensure that the proper substance abuse authorizations are completed for all D&A clients prior to adding the new client to clinical tracker for compliance monitoring.
Clinical supervisors and coordinators will ensure that Clients transferred from the Mental Health program to the D&A program have new consent forms completed that fully comply with Standard 709.28 (c) prior to signing off on the transfer and placing the transferred client on the clinical tracker for compliance monitoring.
Quality Assurance Department (QA) will conduct on-going monitoring throughout each quarter to ensure the correct consents are being used based on D&A program admission and Standards. QA will provide quarterly reports based on the findings with recommendations for continued improvement.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of six applicable client records reviewed.
Client #2 was admitted on February 12, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 12, 2026 and the first update was due no later than April 12, 2026; however, the update was not completed until April 27, 2026. Additionally, the next update was due no later than June 27, 2026; however, the update was not completed as of the date of the inspection.
Client #6 was admitted on October 5, 2025 and was discharged on June 12, 2026. A treatment plan update was completed on April 4, 2026 and the next update was due no later than June 4, 2026; however, the update was not completed until June 11, 2026.
Client #7 was admitted on September 15, 2025 and was discharged on April 10, 2026. The individual treatment and rehabilitation plan was completed on September 22, 2025 and the first update was due no later than November 22, 2025; however, the update was not completed until December 1, 2025.
This is a repeat citation from the August 14, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92(b) LICENSURE
Treatment and rehabilitation services:
Plan of Correction:
In an effort to comply with Standard 709.92(b) Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
In the leadership meeting held on July 22, 2026, site directors and clinical supervisors were reminded of their responsibilities to review the DA Compliance Tracker weekly and to immediately take action to avoid treatment and rehabilitation plans from becoming non-compliant.
A Clinical Supervisors will monitor the DA Compliance Tracker weekly to identify Members with Treatment and Rehabilitation Plans that are approaching the 60-day review date and coordinate the due date in advance with the Counselor and Member.
Treatment and Rehabilitation Plans for Drug and Alcohol members will no longer be driven by regularly scheduled appointments but developed and processed based on the treatment and rehabilitation plan update due date. All efforts will be made to coordinate with the members in advance to obtain input and signatures.
Treatment and Rehabilitation Updates will be finalized electronically every 60-days providing day 60 falls on a workday. In the event of day 60 falling outside of a scheduled workday, the Treatment and Rehabilitation Plan will be finalized within 48 hours prior to the scheduled Treatment and Rehabilitation Plan Update due date.
An addendum to information in the Treatment and Rehabilitation Plans may occur after the finalized Treatment and Rehabilitation Plan Update at the request of the Member, Counselor, or Clinical Supervisory Team.
On-going Monitoring:
Supervisors will monitor treatment and rehabilitation plans weekly using the DA tracker to identify upcoming Treatment and Rehabilitation Plans that are due for a 60-day Update until the member has satisfied the requirements for program discharge.
The QA Department will continue to reconcile the treatment and rehabilitation plan audits weekly to identify treatment plan update completion and those in need of completion based on scheduled appointments.
The Site Director are 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 and treatment outlined in the treatment and rehabilitation plan.
The QA Manager will audit treatment and rehabilitation plans for compliance with 709.92 (b) and for clinical soundness. Aggregate findings per location, per supervisor, per counselor will be reported to the BH Leadership Team Monthly and Quarterly to the Executive Staff. The purpose of pulling aggregate data on each site and employees is to identify gaps in care and to identify if additional training is needed on a site level or individual level.
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Observations
Based on a review of client records, the facility failed to assure counseling services were being provided according to the individual treatment and rehabilitation plan in seven of seven client records reviewed.
Client #1 was admitted on March 9, 2026 and was still active at the time of the inspection. The individual treatment plan completed on March 9, 2026 indicated the client was to receive one group counseling session per week and one individual counseling session per week and the treatment plan update completed on May 6, 2026 indicated the client was to receive one group counseling session per week and one individual counseling session bi-weekly. There was no documentation, in the record, showing the client had received group counseling sessions during the weeks of April 12, 2026, April 26, 2026 and the week of June 7, 2026. Additionally, there was no documentation in the record showing the client had received an individual counseling session during the weeks of March 22, 2026, April 5, 2026, and April 19, 2026.
Client #2 was admitted on February 12, 2026 and was still active at the time of the inspection. The individual treatment plan completed on February 12, 2026 indicated the client was to receive one group counseling session per week and one individual counseling session per week and the treatment plan update completed on April 27, 2026 indicated the client was to receive one group counseling session per week and one individual counseling session bi-weekly. There was no documentation, in the record, showing the client had received group counseling sessions during the weeks of March 1, 2026, March 8, 2026, April 12, 2026, April 26, 2026, May 3, 2026, May 24, 2026, May 31, 2026, and June 21, 2026. Additionally, there was no documentation in the record showing the client had received individual counseling sessions during the weeks of March 8, 2026, April 5, 2026, and April 12, 2026.
Client #3 was admitted on February 12, 2026 and was still active at the time of the inspection. The individual treatment plan completed on February 12, 2026 and the treatment plan updates completed on April 10, 2026 and June 1, 2026, indicated the client was to receive one group counseling session per week and one individual counseling session bi-weekly. There was no documentation, in the record, showing the client had received group counseling sessions during the weeks of March 1, 2026, March 8, 2026, April 12, 2026, May 10, 2026, and June 16, 2026. Additionally, there was also no documentation, in the record, showing the client had received an individual counseling session during the week of March 22, 2026.
Client #4 was admitted on March 16, 2026 and was discharged on May 6, 2026. The individual treatment plan dated March 16, 2026 indicated the client was to receive one group counseling session per week and one individual counseling session bi-weekly. There was no documentation in the record showing the client had received a group counseling session for the weeks of March 22, 2026, March 29, 2026, April 5, 2026 and April 12, 2026.
Client #5 was admitted on December 4, 2025 and was discharged on April 9, 2026. The individual treatment plan completed on December 4, 2025 and the treatment plan updates completed on January 15, 2026, February 19, 2026, and March 21, 2026 indicated the client was to receive one group counseling session per week and one individual counseling session bi-weekly. There was no documentation, in the record, showing the client had received a group counseling session during the weeks of February 8, 2026, February 15, 2026, and March 8, 2026.
Client #6 was admitted on October 5, 2025 and was discharged on June 12, 2026. The individual treatment plan completed on November 21, 2025 and the treatment plan updates completed on January 9, 2026, February 6, 2026, April 6, 2026, and June 11, 2026 indicated the client was to receive one group counseling session per week and one individual counseling session bi-weekly. There was no documentation, in the record, showing the client had received group counseling sessions during the weeks of November 30, 2025, January 18, 2026, January 25, 2026, February 15, 2026, February 22, 2026, March 8, 2026, March 15, 2026, and every week during the period of April 12, 2026 through June 12, 2026.
Client #7 was admitted on September 15, 2025 and was discharged on April 10, 2026. The individual treatment plan completed on September 22, 2025 and the treatment plan updates completed on December 1, 2025, January 29, 2026, and March 30, 2026 indicated the client was to receive one group counseling session per week and two individual counseling sessions per month. There was no documentation, in the record, showing the client had received group counseling sessions during the weeks of October 12, 2025, February 22, 2026, March 15, 2026, March 22, 2026, and March 29, 2026.
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 ensure that counseling services are provided according to the individual treatment and rehabilitation plan.
To ensure compliance with §709.92(c), the Program has implemented procedures to ensure counseling services are delivered in accordance with each member's individual treatment and rehabilitation plan while supporting member engagement, individualized care, and value-based treatment principles.
Effective July 27, 2026, treatment and rehabilitation plans will utilize a flexible, member-centered approach that allows treatment services to be based on the member's clinical needs, treatment goals, preferences, and ability to participate in treatment. Counselors and members will collaborate to establish an appropriate treatment schedule that promotes recovery and meaningful engagement in services.
The treatment and rehabilitation plan will generally encourage members to participate in a minimum of three treatment services per month, which may include any combination of: Individual counseling sessions; and/or Group therapy sessions.
Members may participate in up to eight treatment services per month when clinically indicated and mutually agreed upon by the member and counselor. Additional services scheduled will be documented in the plan section of the progress note with clinical justification as needed. The impact of additional services received will be discussed in the updated treatment and rehabilitation plan.
In addition to counseling services, members may access other supportive services as clinically appropriate, including: Peer Support Services, Community Health Worker Services, Psychiatric Evaluation, and Medication Management Services.
Members who fail to attend a scheduled treatment session will receive follow-up and reengagement efforts consistent with agency policy. Engagement interventions may include appointment reminders, telephone outreach, motivational interventions, and other clinically appropriate activities intended to support continued participation in treatment.
If a member is unable to participate in the minimum anticipated treatment frequency despite engagement efforts, the treatment and rehabilitation plan will be reviewed and revised to reflect the member's current level of participation, clinical needs, treatment goals, and readiness for treatment. Modifications to service frequency will be documented in the clinical record and incorporated into the updated treatment and rehabilitation plan.
Monitoring and Oversight
Clinical Supervisors will ensure that the frequency of individual counseling and group therapy sessions identified in each treatment and rehabilitation plan is entered into the DA Tracker. The DA Tracker will be reviewed weekly to monitor compliance with scheduled treatment frequency and identify members who may require additional outreach, treatment plan review, or engagement interventions.
Clinical Supervisors will document monitoring activities and provide ongoing oversight to ensure counseling services are delivered in accordance with the individualized treatment and rehabilitation plan and remain compliant with §709.92(c).
Quality Assurance
As part of the program's continuous quality improvement process, treatment scheduling and service utilization data will be reviewed regularly to ensure counseling services are being provided in accordance with member treatment plans. Findings will be used to identify opportunities for improvement in treatment engagement, service delivery, and compliance with §709.92(c).
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