Observations
Based on a review of client records, the facility failed to ensure the consent to treatment documentation was obtained as part of the intake procedures in seven of seven client records reviewed.
In every client record reviewed, there was no consent to treatment documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new consent of treatment form was created on 11/19/2024 and added to the Intake packet. All new clients will sign this document along with other documents before starting the treatment. This will prevent this deficiency from occurring with all new clients. This same form is used to get signatures from existing clients. The front desk staffs are actively works with all existing clients, calling on their phones and inviting them to come to the clinic to sign the document. Program Director will be responsible for implementing this task. |
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in four of six applicable client records reviewed.
Client #4 was admitted on April 1, 2024 and was discharged on August 12, 2024. The individual treatment and rehabilitation plan was completed on April 3, 2024 and the first treatment plan update was due no later than June 3, 2024; however, the update was completed on July 8, 2024.
Client #5 was admitted on June 24, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 30, 2024 and the first treatment plan update was due no later than August 30, 2024; however, the update was completed on September 27, 2024.
Client #6 was admitted on March 19, 2024 and was active at the time of the inspection. A treatment plan update was completed on August 13, 2024 and the next treatment plan update was due no later than October 13, 2024; however, the update was completed on November 1, 2024.
Client #7 was admitted on April 9, 2024 and was active at the time of the inspection. A treatment plan update was completed on August 19, 2024 and the next treatment plan update was due no later than October 19, 2024; however, the update was not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The matter was addressed with the substance abuse counselor. Memos were issued for delayed documentation, and individual supervision was provided on completing the treatment plan every 60th day. A spreadsheet will be shared between substance abuse counselors and supervisor with information on treatment plan due dates and the supervisor will monitor and remind substance abuse counselor to complete them on time. |