Observations
Based on a review of client records, the facility failed to document whether a client participated in the development of the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client #2 was admitted on January 5, 2024, and was active at the time of the licensing inspection. A comprehensive treatment plan completed on February 5, 2024, did not have written documentation that the client participated in the development of the comprehensive treatment plan.
Client #3 was admitted on May 29, 2024, and was active at the time of the licensing inspection. A comprehensive treatment plan completed on June 29, 2024, did not have written documentation that the client participated in the development of the comprehensive treatment plan.
Client #4 was admitted on November 27, 2023, and was discharged on January 13, 2024. A comprehensive treatment plan completed on December 27, 2024, did not have written documentation that the client participated in the development of the comprehensive treatment plan.
This is a repeat citation from the November 21, 2023 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
MARS' upcoming EHR features a client portal which allows the ability for clients to access and sign their treatment plans in an efficient manner at the time of collaborating with their
counselor for development.
Counselors will also be retrained within the next 60 days by the Quality Assurance Department and instructed to document in their clinical notes when a treatment plan has been developed with the client. MARS Quality Assurance department will audit clinical notes for this documentation.
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Observations
Based on the review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client #1 was admitted on January 8, 2024, and was active at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on January 16, 2024, indicated that the client was to receive one individual counseling session and one group counseling session per week; however, there were no individual counseling sessions documented for the weeks of March 4, 2024 through March 8, 2024, March 11, 2024 through March 15, 2024, March 25, 2024 through March 29, 2024, April 29, 2024 through May 3, 2024, May 6, 2024 through May 10, 2024, May 27, 2024 through May 31, 2024, June 3, 2024 through June 7, 2024, June 17, 2024 through June 21, 2024, July 1, 2024 through July 5, 2024, July 8, 2024 through July 12, 2024, July 22, 2024 through July 26, 2022, July 29, 2024 through August 2, 2024, August 12, 2024 through August 16, 2024, August 19, 2024 through August 23, 2024, August 26, 2024 through August 30, 2024, September 2, 2024 through September 6, 2024 and September 9, 2024 through September 13, 2024. Additionally, there were no group counseling session documented for the months of April 2024, May 2024, June 2024, July 2024 and August 2024.
Client #2 was admitted on January 5, 2024, and was active at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on February 5, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented for the weeks of May13, 2024 through May 17, 2024, May 20, 2024 through May 24, 2024 and May 27, 2024 through May 31, 2024.
Client #4 was admitted on November 27, 2023, and was discharged on January 13, 2024. A preliminary treatment and rehabilitation plan, documented in the client record on November 27, 2023, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions for the months of December 2023 or January 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A retraining plan will be developed with clinicians within the next 60 days by the Quality Assurance Department overviewing documentation protocol when clients are a no-show and/or unable to follow their preliminary treatment plan as outlined at time of assessment.
If a client is found to meet criteria for less frequent contact than indicated in the preliminary treatment plan, it will be documented in a case consultation.
No show notes will be documented by clinicians to reflect client attendance (show or no show)- Quality Assurance Staff will audit medical records to ensure that there is documentation submitted in the file reflecting this and that inactive clients who are beyond 30 days are being discharged appropriately.
MARS' client care coordinator will contact clients who are inconsistent or who are struggling to connect with their treatment team to ensure that logistical barriers are addressed and to liaise between clinical team and client. The client care coordinator will document outreach efforts in the EHR.
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