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 six out of seven records reviewed.
Client #1 was admitted on February 11, 2025 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on February 20, 2025, 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 March 9, 2025 through March 15, 2025 and April 6, 2025 through April 12, 2025.
Client #2 was admitted on December 12, 2024 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on December 19, 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 January 19, 2025 through January 25, 2025, February 16, 2025 through February 22, 2025 and February 23, 2025 through March 1, 2025.
Client #3 was admitted on November 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 November 14, 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 November 24, 2024 through November 30, 2024, January 19, 2025 through January 25, 2025, February 9, 2025 through February 15, 2025, February 16, 2025 through February 22, 2025, March 16, 2025 through March 22, 2025 and April 6, 2025 through April 12, 2025.
Client #5 was admitted on July 18, 2024 and was discharged on October 29, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on July 25, 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, August 25, 2024 through August 31, 2024, September 15, 2024 through September 21, 2024 and September 22, 2024 through September 28, 2024.
Client #6 was admitted on September 16, 2024 and was discharged on February 12, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on October 3, 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 27, 2024 through November 2, 2024, December 15, 2024 through December 21, 2024, December 22, 2024 through December 28, 2024, December 29, 2024 through January 4, 2025, January 19, 2025 through January 25, 2025 and February 2, 2025 through February 8, 2025. Additionally, there were no individual counseling sessions documented in the client record for the month of November 2024.
Client #7 was admitted on August 29, 2024 and was discharged on December 27, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on October 31, 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 November 17, 2024 through November 23, 2024, November 24, 2024 through November 30, 2024 and December 8, 2024 through December 14, 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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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosure is to be made in four of seven client records reviewed.
Client #1 was admitted on February 11, 2025 and was a current client at the time of the inspection. Two releases of information, signed by the client on January 23, 2025, did not document the name of the person, agency or organization to whom disclosures are to be made.
Client #2 was admitted on December 12, 2024 and was a current client at the time of the inspection. Two releases of information, signed by the client on December 2, 2024, did not document the name of the person, agency or organization to whom disclosures are to be made.
Client #3 was admitted on November 7, 2024 and was a current client at the time of the inspection. A release of information, signed by the client on August 13, 2024, did not document the name of the person, agency or organization to whom disclosure is to be made.
Client #6 was admitted on September 16, 2024 and was discharged on February 12, 2025. A release of information, signed by the client on September 16, 2024, did not document the name of the person, agency or organization to whom disclosure is to be made.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When a patient declines to have their primary health provider notified of involvement in treatment or does not have a primary health provider the release is completed as follows:
1. Patient name and Date of Birth are entered on the form for identification.
2. Not Applicable or "N/A" is written in the disclose and communicate section of the form.
3. Not Applicable or "N/A" is written in the patient signature/date area of the form
4. Check boxes (__) will be added to the medical provider consent form as follows:
(a).(__) Patient declines consent to primary health provider (Patient will initial/date)
(b).(__) No primary health provider reported (Patient will initial and date).
5.Revision of form: Date: 5/12/25
6. Communication to staff Date:5/20/25
7. Compliance monitoring: Random audit of two charts June 1,2025 to September 30,2025
Responsible person(s) for all steps above: Program Director/Clinical Supervisor
Start date: 6/1/25 End Date: 9/30/25.
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