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 four out of seven applicable records reviewed.
Client #1 was admitted on February 5, 2024, and discharged on August 29, 2024. The treatment plan dated February 15, 2024, indicated one individual session weekly. There was no documentation of the client receiving individual therapy for the week of March 24-30, 2024.
Client #2 was admitted on April 26, 2024 ad was still active at the time of the inspection. The treatment plan dated May 15, 2024, indicated one individual session biweekly and two group sessions weekly. There was no documentation the client received two group sessions for the weeks of May 19-25, 2024, May 26-June 1, 2024, June 23-29, 2024, August 18-24, 2024, or September 1-7, 2024.
Client #4 was admitted on April 8, 2024 and discharged on August 28, 2024. The treatment plan dated April 29, 2024, indicated one individual session weekly. There was no documentation of the client receiving individual therapy for the weeks of May 12-18, 2024, May 26-June 1, 2024, or June 2-8, 2024.
Client #5 was admitted on July 03, 2024, and was still active at the time of the inspection. The treatment plan dated July 10, 2024, indicated one individual session biweekly and three group sessions weekly. There was no documentation of the client receiving three group sessions for the weeks of August 4-10, 2024, August 11-17, 2024, August 18-24,2024, August 25-31, 2024, September 8-14, 2024, September 15-21, 2024, or September 29-October 5, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During a clinical staff meeting held on 2/12/2025, clinicians reviewed the importance of following treatment schedules identified in comprehensive treatment plans. The following protocol will be implemented immediately to ensure that clients meet their treatment schedule identified in their comprehensive treatment plans:
All weekly and bi-weekly clients will be scheduled for two individual sessions at whatever treatment schedule they have agreed to. If a client misses an appointment, all attempts will be made to accommodate their treatment schedule including being seen by another clinician if their primary counselor does not have availability.
This new protocol will be monitored by the clinical supervisor and QM coordinator. |