Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #1 was admitted on August 15, 2025 and was active at the time of the inspection. The facility failed to document releases of information forms for the family members and a friend that participated in family counseling sessions that took place on August 30, 2025, September 6, 2025, September 12, 2025, and September 23, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CEO created and implemented a policy that all counselors and case managers will check all releases for family visits before they enter the building for visits. If there is no release signed, there will be one signed prior to the visit to ensure confidentiality of all clients.
Chief Clinical Officer (CCO) will monitor the consents and releases weekly and ensure clinical staff is adhering to the policy. CCO will continue to monitor this process.
This was discussed with Client #1 and was understood. |
Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include progress notes entered within twenty-four hours of the date of service, per the facility's policy, in four of seven records reviewed.
Client #1 was admitted on August 15, 2025 and was a current client at the time of the inspection. The record contained a progress note for an individual counseling session occurring on September 3, 2025, and September 10, 2025, that were not documented until September 8, 2025, and September 18, 2025, respectively.
Client #2 was admitted on August 12, 2025 and was a current client at the time of the inspection. The record contained progress notes for individual counseling sessions occurring on September 4, 2025, September 10, 2025, and September 16, 2025, that were not documented until September 8, 2025, and September 22, 2025, respectively.
Client #3 was admitted on August 13, 2025 and was an active client at the time of the inspection. The record contained progress notes for individual counseling sessions occurring on August 16, 2025, August 20, 2025, and August 22, 2025, that were not documented in the record until August 26, 2025. Additionally, the record contained a progress note for an individual counseling session occurring on September 2, 2025, that was not documented in the record until September 9, 2025, counseling session occurring on September 9, 2025, that were not documented in the record until September 16, 2025, and counseling sessions occurring on September 15, 2025, and September 16. 2025 that were not documented in the record until September 23, 2025.
Client #4 was admitted on August 6, 2025 and was involuntarily discharged on September 24, 2025. The record contained progress notes for individual counseling sessions occurring on August 27, 2025, and September 17, 2025, that were not documented in the record until September 2, 2025, and September 24, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CEO changed policies for timeliness of submitting and signing off on progress notes to allow for a week to submit and sign off on progress notes and counseling sessions.
Chief Clinical Officer will continue her weekly chart audits to ensure timeliness is in accordance with our policies. |