Observations
Based on client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in five of seven applicable records.
The facility policy and procedure manual indicates a case consultation to occur within the first ninety days of treatment, then annually thereafter.
Client #1 was admitted on July 18, 2023 and still active at the time of the inspection. A case consultation was due to occur no later than October 18, 2023, however this was not completed until November 11, 2023.
Client #2 was admitted on June 12, 2023 and still active at the time of the inspection. A case consultation was due to occur no later than September 12, however this was not completed until September 28, 2023.
Client #5 was admitted on May 10, 2023 and discharged on October 17, 2023. A case consultation was due to occur no later than August 10, 2023, however this was not completed until October 17, 2023.
Client #6 was admitted on May 1, 2023 and discharged December 11, 2023. A case consultation was due to occur no later than August 1, 2023, however this was not completed until December 4, 2023.
Client #7 was admitted on March 3, 2023 and discharged on July 24, 2023. A case consultation was due to occur no later than June 3, 2023, however there was no documentation of a case consultation in the client record.
This is a repeat citation from the February 2, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As outlined at the start of this licensing visit our supervisory team had previously documented and addressed concerns related to a specific employee that resulted in incomplete and late documentation. Multiple client charts that were reviewed during this licensing visit were impacted by this individual. It is noted that this employee was no longer with the agency at the time of the on-site inspection. Clinical Supervisor will retrain all current clinical staff during the regularly scheduled team meeting on 1/16/24 with a focus on SPHS internal policy and DDAP Regulatory Standards for ensuring that all clients have a case consultation documented in their EHR within 90 days of admission and then annually thereafter. A group supervision form will be completed and signed by all clinical staff participants acknowledging they have been re-trained in this requirement. Clinical staff that are not present, based on their in-office availability, will review the information with the Clinical Supervisor at their next scheduled individual supervision and will sign the individual supervision log confirming re-training of this requirement. A copy of both the group supervision form and each individual supervision log will be sent to the Clinical Director to confirm that the training occurred. To ensure that the initial case consultation is completed for each individual each assessment will be reviewed by the clinical team during weekly Group Supervision and a case consultation note will be documented. For ongoing treatment, clinicians will maintain an accurate record of when case consultations are due for each individual. This will be reviewed at least monthly by clinical supervisor as evidenced by supervision note and/or client record. In addition, clinical staff will be trained on how to extract data from the EHR record to confirm any upcoming case consultations that are coming due. Case consultations will be reviewed during random chart reviews and documented in the client record through either the Chart Review service in the EHR or scanned into the client chart. A mock audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will confirm that case consultations are occurring as required throughout an individual's treatment. |