Observations
Based on a review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in seven of seven client records reviewed.
Client #1 was admitted on November 14, 2024 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on November 21, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling sessions documented in the client record for the weeks of December 15, 2024 through December 21, 2024, January 19, 2025 through January 25, 2025, February 2, 2025 through February 8, 2025, February 23, 2025 through March 1, 2025 March 9, 2025 through March 15, 2025 and March 30, 2025 through April 5, 2025.
Client #2 was admitted on October 7, 2024 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on October 16, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling sessions documented in the client record for the weeks of October 20, 2024 through October 26, 2024 and November 3, 2024 through November 9, 2024. Additionally, an updated treatment and rehabilitation plan, documented in the client record on December 11, 2024, indicated that the client was to receive two individual counseling session per month; however, there was no individual counseling sessions documented in the client record for the months of January 2025 and March 2025.
Client #3 was admitted on October 1, 2024 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on October 16, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling sessions documented in the client record for the weeks of October 20, 2024 through October 26, 2024 and November 3, 2024 through November 9, 2024. Additionally, an updated treatment and rehabilitation plan, documented in the client record on December 11, 2024, indicated that the client was to receive two individual counseling session per month; however, there was only one session documented in the record for the month of February 2025.
Client #4 was admitted on July 8, 2024 and was discharged on December 12, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on July 22, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling sessions documented in the client record for the weeks of August 18, 2024 through August 24, 2024, September 8, 2024 through September 14, 2024, October 20, 2024 through October 26, 2024, October 27, 2024 through November 1, 2024, November 3, 2024 through November 9, 2024, November 10, 2024 through November 16, 2024, November 24, 2024 through November 30, 2024, December 8, 2024 through December 14, 2024, December 15, 2024 through December 21, 2024, December 29, 2024 through January 4, 2025 and February 2, 2025 through February 8, 2025.
Client #5 was admitted on October 8, 2024 and was discharged on March 26, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on October 9, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling sessions documented in the client record for the weeks of December 1, 2024 through December 7, 2024, December 15, 2024 through December 21, 2024, December 22, 2024 through December 28, 2024, January 12, 2025 through January 18, 2025, January 26, 2025 through February 1, 2025, February 9, 2025 through February 15, 2025, February 16, 2025 through February 22, 2025 and March 2, 2025 through March 8, 2025. Additionally, there was no individual counseling sessions documented in the client record for the month of November 2024.
Client #6 was admitted on September 13, 2024 and was discharged on January 7, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on September 16, 2024, indicated that the client was to receive two individual counseling session per month; however, there was only one individual counseling sessions documented in the client record for the months of October 2024 and November 2024.
Client #7 was admitted on September 24, 2024 and was discharged on February 11, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on October 9, 2024, indicated that the client was to receive two individual counseling session per month; however, there was only one individual counseling sessions documented in the client record for the months of October 2024, November 2024 and December 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Treatment Plans on all new admissions will add "a minimum of" (frequency) for individual/group modalities.
Start Date: 6/2/25 Responsible person(s): Program Director/Clinical Supervisor.
2. Patients active in treatment prior to 6/2/25 will have this protocol completed when a treatment plan update is necessary.
Start Date: 6/2/25 Responsible person(s): Program Director/Clinical Supervisor.
3.Protocol communicated to clinical team at team meeting. Date: 5/25/25 Responsible person(s): Program Director/Clinical Supervisor
4. Monitoring of missed clinical sessions
will be daily and monthly.
Monthly: A report will be generated monthly listing cancelled and No-show appointments for all active patients and will include assigned counselor, patient, scheduled date and appointment date.
4.(a) This report will be distributed to clinical team and discussed in individual and group supervision. Responsible Person(s): Program Director, Clinical Supervisor, Clinical Team. Target Date: June 6,2025
4(b) Decisions regarding treatment plan update type and frequency revisions will occur based upon criteria in the report as well as other clinical factors. Responsible Person(s): Program Director, Clinical Supervisor, Clinical Team. Target Date: June 6,2025
4(c). Daily: Follow up will occur on missed sessions within 1 day of the missed session. A member of the clinical team will call patients to determine the reason for the missed session. In the event they are unable to speak with the patient a message will be left requesting the patient to reschedule the appointment. If a message cannot be delivered a follow-Up letter is sent to the patient. Responsible Person(s): Program Director, Clinical Supervisor, Clinical Team. Target Date: June 6,2025
4(d). Documentation of attempts to follow up with the patient will be charted in the clinical record as a "Documentation Note" and/or a follow up letter. Responsible Person(s): Program Director, Clinical Supervisor, Clinical Team. Target Date: June 6,2025
5.(a) Compliance Monitoring: Random chart audit (2 charts per counselor/month) June 2025 to October 2025.
Responsible person(s): Program Director/Clinical Supervisor
5(b). One chart per counselor/month November 2025 to December 2025.
Responsible person(s): Program Director/Clinical Supervisor.
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