Observations
Based on a review of client records, the facility failed to ensure individual counseling was provided at least twice weekly.
Client # 1 was admitted December 6, 2023, and discharged January 10, 2024. During the week of December 31, 2023, through January 6, 2024, the record of service and progress notes indicated that the client received one individual session that week, on January 4, 2024. There was no documentation observed in the chart to indicate the client canceled or did not attend a second scheduled individual session that week.
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Plan of Correction
The Facility will ensure compliance to deficiency(s)represented through observation #1571. The Facility Executive Director is responsible for staff compliance all Facility policies and procedures. Executive Director is responsible for administrative and clinical policy and procedural compliance to the most rigorous regulatory standards.
The Clinical Director is responsible for
clinical policy procedural compliance. The Clinical Director will ensure all clients are scheduled for Individual and group therapy in accordance with the evaluated Level of Care (LOC) consistent with American Society of Addiction medecine (ASAM) criteria.
The Clinical director is responsible for ensuring all clients are scheduled for individual therapy sessions assigned through their current LOC.
Clinical Director will train all clinical staff members during the Employee Orientation period on regulatory standards and compliance specifically regarding DDAP and ASAM requirements related to LOC criteria and LOC treatment modality.
The Clinical Director is the QA agent responsible for assurance that clinical staff members engaging Partial Hospitalization Program (PHP) clients schedule and complete the assigned LOC session hours and documentation of therapy services.
Clinical Director will perform weekly QA audits on all PHP clinical records.
Clinical Therapist assigned to a PHP client is responsible for documentation of clinical service schedule and client awareness of individual therapy scheduled dates/times of scheduled session.
All individual therapy sessions are documented by the therapist within 24 hours of the scheduled session completion.
If a client cancels a scheduled individual session, the therapist will document the date, time. and reason for the cancellation. The therapist is responsible for notification and documentation of the cancellation.
If a client fails to attend a scheduled individual therapy session, the Therapist must attempt to contact client through phone/text methods. Therapist is responsible for documentation of missed session reason and rescheduling of session. Therapist is responsible for continued client contact attempts, outcomes, and clinical record documentation of attempts.
Weekly chart audits by the Clinical Director will ensure appropriate documentation is noted in the chart for both active and discharged clients.
This corrective action plan will take place 06/26/2024.
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