Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients. The facility failed to follow their policy related to Against Staff Advice (ASA) discharges by calling the Emergency Contact within twelve hours in one of three applicable records reviewed.
Client #6 was admitted to the inpatient non-hospital detoxification level of care on November 16, 2024 and was discharged Against Staff Advice (ASA) on November 19, 2024. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. Immediate Corrective Action:
- On June 3, 2025, the Clinical Supervisor met with the staff involved to review the missed Emergency Contact notification for Client #6 and reinforced the required protocol for ASA discharges.
2. Policy Review and Staff Re-Education:
- By June 30, 2025, all clinical staff (including counselors and other relevant personnel) will participate in a mandatory staff meeting to review the facility's ASA discharge policy and procedures.
- The meeting will specifically include:
o A detailed review of the ASA discharge workflow checklist, with emphasis on the requirement to contact the Emergency Contact within twelve (12) hours of discharge.
o Clarification of documentation standards, including recording all contact attempts and successful notifications in the client record.
- All participating staff will be required to sign an acknowledgment form confirming their understanding of and commitment to following these procedures.
3. Ongoing Monitoring and Quality Assurance:
- For every client who discharges Against Staff Advice (ASA), an email notification will be sent to all relevant staff confirming that:
o The client's Emergency Contact was notified within the required timeframe.
o The notification and all related documentation have been properly completed in the client record.
- The Clinical Supervisor and Compliance Team will alternate conducting monthly audits, with a specific focus on ASA discharges to ensure Emergency Contact notifications are being completed within the required timeframe.
- Audit findings will be documented and shared with the Program Director as well as shared during monthly Continuous Quality Improvement (CQI) meetings to monitor compliance and identify any further training needs. |
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 seven days of the date of service, per the facility's policy, in four of seven applicable records reviewed.
Client #8 was admitted on March 27, 2025 and was a current client at the time of the inspection. The record contained group counseling session progress notes for April 28, 2025, and May 9, 2025 that were not documented in the record until May 24, 2025.
Client #11 was admitted on September 10, 2024 and was discharged on October 7, 2024. The record contained group counseling session progress notes for September 23, 2024, and September 25, 2024, that were not documented in the record until October 3, 2024, and October 7, 2024.
Client #12 was admitted on October 17, 2024 and was discharged on December 17, 2024. The record contained progress notes for group counseling sessions occurring on October 28, 2024 that were not documented until November 13, 2024; session occurring on October 30, 2024 that was not documented until December 9, 2024; session occurring on November 2, 2024 that was not documented until November 14, 2024; session occurring on November 3, 2024 that was not documented until November 19, 2024; session occurring on November 4, 2024 that was not documented until November 30, 2024; session occurring on November 13, 2024 that was not documented until November 30, 2024; session occurring on November 17, 2024 that was not documented until December 28, 2024; session occurring on November 18, 2024 that was not documented until December 31, 2024; session occurring on November 27, 2024 that was not documented until December 30, 2024; session occurring on November 30, 2024 that was not documented until December 30, 2024; and, session occurring on December 1, 2024 that was not documented until December 30, 2024.
Client #14 was admitted on January 13, 2025 and was discharged on February 4, 2025. The record contained progress notes for group counseling sessions occurring on January 14, 2025, that were not documented until January 24, 2025; session occurring on January 15, 2025 that was not documented until January 30, 2025; and session occurring on February 4, 2025 that was not documented until February 13, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. Immediate Corrective Action:
-On June 3, 2025, the Clinical Supervisor met with the staff members responsible for the late documentation and reviewed client #8, #11, #12, #14. Staff were reminded of the facility's policy requiring progress notes to be entered within seven (7) days of the service date.
2. Policy Review and Staff Re-Education:
-By June 30, 2025, all clinical staff (including counselors and other relevant personnel) will participate in a mandatory clinical meeting to review the facility's progress note completion timelines.
-This meeting will specifically cover:
o A comprehensive review of the facility's policy regarding progress note documentation, with particular emphasis on the requirement that all progress notes must be entered within seven (7) calendar days of the service date.
o Strategies for effective time management and prioritization of charting responsibilities to ensure timely and accurate recordkeeping.
3. Ongoing Monitoring and Quality Assurance:
-The Clinical Supervisor will conduct weekly spot check audits for a period of 90 days to ensure each counselor is completing progress notes accurately and within required timeframes.
-Monthly audits will be completed with a specific focus on verifying compliance with progress note requirements.
-As part of the existing CQI audit process, a representative percentage of each counselor's caseload will be reviewed monthly to monitor for accuracy and to ensure all progress notes are entered within 7 days of the date of service. |