Observations
Based on a review of four out of four patient records, the program failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first two years, one hour of which shall be individual psychotherapy.
Patient #1 was admitted on May 22, 2020 and was current at the time of the inspection. Patient #1 had forty minutes of individual psychotherapy in December 2020 and thirty five minutes of individual psychotherapy in January 2021. Patient #1 had no group psychotherapy in December 2020 or January 2021.
Patient #2 was admitted on May 1, 2020 and was discharged on February 23, 2021. Patient #2 had no psychotherapy documented in the past three months.
Patient #3 was admitted on November 2, 2020 and was current at the time of the inspection. Patient #3 had forty minutes of individual psychotherapy in November 2020. Patient #3 had no other psychotherapy documented.
Patient #4 was admitted on March 9, 2020 and was discharged on July 8, 2020. Patient #4 had no psychotherapy documented during this time period.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Effective 2/24/21, the Executive Director, met with all clinical supervisors, Case Management supervisors and Medication Assisted Treatment workers to inform them that all clients within the first two years of MAT and treatment, all clients must have a minimum of 2.5 hours of psychotherapy, one hour of which must be individual psychotherapy. Effective 2/24/2021, an email went out to all staff with the regulation attached reminding them of the amount of counseling required for MAT. Effective 3/1/2021, all supervisors will monitor clients attendance and staff will be reminded monthly to ensure proper attendance.
Effective 3/1/2021, Patient 1-4, if still in treatment will be scheduled for a minimum of 2.5 hours of treatment per month with at least 1 hour (60 min) of individual psychotherapy. Clinical Supervisor will monitor all client attendance to ensure compliance. |