Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client ' s treatment at the project, which is to include the reason for termination in one of two applicable client records.
Client #4 was admitted on June 1, 2022 and was administratively discharged on July 28, 2022. There was no documentation in the record indicating the client was notified in writing of the facility ' s decision to involuntarily terminate the client ' s treatment at the project.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Counselor Assistant attended a meeting/training held by the Facility Director and Project Director on Friday, January 27, 2023. Regulation 709.33(a) was reviewed at that time regarding the notification of termination. In the event that an involuntary termination occurs in the future the Facility Director will ensure that the appropriate notification of termination is completed prior to the termination and reviewed with the client. |
Observations
Based on a review of client records and unusual incident reports, the facility failed to report the outbreak of a contagious disease to the Department in one of one incident. Client #2 was admitted on April 28, 2022 and discharged on August 9, 2022. Documentation found in the client record indicated an incident occurred on July 17, 2022, but was not reported to the Department as of the date of the inspection.
These findings were reviewed with staff during the licensing process.
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Plan of Correction
The Project Director, Facility Director, Clinical Supervisor and Counselor Assistant attended a meeting/training on Friday, January 27, 2023. The Department of Drug and Alcohol Program's Electronic Reporting System (ERS) was reviewed. The Facility Director and Project Director will ensure that any incident requiring submission to the DDAP ERS is completed within 3 business days. |
Observations
Based on a review of client records, the facility failed to maintain records of services in eight of eight client records. Zero client records contained a record of service for services provided during the weekend. Six of eight client records were missing the following:
Client #1 was admitted on July 12, 2022 and discharged on August 29, 2022. The record of service is missing entries for July 15 - 26 and August 7, 8, 14, 15, 21, 22, 2022
Client #2 was admitted on April 28, 2022 and discharged on August 9, 2022. The client record contained individual session progress notes documented for July 28 and August 9, 2022, but were not documented on the record of service. Record of service entries are missing for May 1, 2, 8, 9, 16, 22, 23, June 5, 12, 13, 19, 20, July 3, 4, 10, 15, August 7, and 8, 2022.
Client #4 was admitted on June 1, 2022 and discharged on July 28, 2022. The client record contained a family therapy progress note was documented on July 6, 2022 but was not documented on the record of service. The client record also contained a group therapy note was documented on July 27, 2022, but was not documented on the record of service. Record of service entries are missing for the following dates: June 26, 27, July 16 - July 28, 2022.
Client #5 was admitted on January 12, 2023 and remains in the treatment program as of the inspection. The client record contained an individual therapy progress note was documented on January 17, 2023 but not documented on the record of service.
Client #6 was admitted on July 27, 2022 and remains in the treatment program as of the inspection. The client record contained an individual session on January 5, 2023 and group therapy on December 24, 2022 were documented on progress notes, but were not documented on record of service.
Client #8 was admitted on November 1, 2022 and remains in the treatment program as of the inspection. The client record of service is missing entries for November 6, 7, 13, 27, 28, December 4, 5, 11, 12, 18, 19, 2022. No record of service for January, however the client record did have an individual session progress note documented for January 5, 2023.
These findings were reviewed with staff during the licensing process.
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Plan of Correction
The Project Director, Facility Director, Clinical Supervisor and Counselor Assistant attended a meeting/training on Friday, January 27, 2023. Record of Service regulations were reviewed. The Clinical Supervisor and Counselor Assistant, along with the direct care staff, are responsible for ensuring that the Record of Service is accurate and updated on a daily basis. The Facility Director will conduct Record of Service chart audits at the beginning of each month for the preceding month.
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