Observations
Based on a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of three applicable records reviewed.
Client #2 was admitted on August 20, 2024, and was still active at the time of the inspection. The treatment plan dated December 17, 2024, indicated two group sessions per week. There was no documentation that the client received both group sessions for the weeks of: January 5-January 11, 2025; January 12-18, 2025; January 19-25, 2025, and January 26-February 1, 2025;
Client #5 was admitted on March 6, 2024, and was discharged on August 20, 2024. The treatment plan dated May 21, 2024, indicated weekly individual sessions. There was no documentation that the client received individual sessions between June 8-June 14, 2024, and June 22-June 28, 2024.
Client #6 was admitted on May 21, 2024, and was discharged on January 7, 2025. The treatment plan dated June 11, 2024, indicated weekly individual sessions. There was no documentation that the client received individual session July 13-July 19, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all requirements regarding treatment and rehabilitation services, and specifically regarding providing counseling services according to the individual treatment plan
Each of the above situations were due to clients failing to attend scheduled appoints, staff being out of the office, or the frequency of services being decreased during the period in between treatment planning sessions. We recognize the importance of the regulation and are making steps to improve documentation.
All clinical supervisors have been retrained on the necessary requirements of a treatment plan including the requirement to update treatment plans any time the frequency of treatment has been increased or decreased. The clinical supervisors will be reviewing this with all clinical staff in clinical supervision. Additionally, the clinical supervisors will be working with the staff to more consistently document missed appointments that result regardless of whether or not they are caused by the client missing the appt or the counselor being out of the office. In addition, our compliance team has been retrained on treatment plan requirements and will be further monitoring this item while conducting file audits. Lastly, the director will follow up quarterly to ensure continued compliance.
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