Observations
Based on the review of outpatient client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in four of seven records reviewed.Client #1 was admitted on February 16, 2024 and was a current client at the time of the licensing inspection. An updated treatment and rehabilitation plan was documented in the record on April 19, 2024, and the next update was due no later than June 19, 2024; however, a treatment plan update was not documented in the record until September 20, 2024.Client #2 was admitted on March 15, 2024 and was a current client at the time of the licensing inspection. An updated treatment and rehabilitation plan was documented in the record on September 13, 2024, and the next update was due no later than November 13, 2024; however, a treatment plan update was not documented in the record at the time of the inspection.Client #4 was admitted on December 8, 2023, and was discharged on April 26, 2024. A comprehensive treatment and rehabilitation plan was documented in the record on December 8, 2023, and the update was due no later than February 8, 2024; however, a treatment plan update was not documented in the record until March 1, 2024.Client #7 was admitted on March 27, 2024, and was discharged on November 15, 2024. An updated treatment and rehabilitation plan was documented in the record on September 2, 2024, and the update was due no later than November 2, 2024; however, a treatment plan update was not documented in the record at the time of the inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Brighter Visions Counseling acknowledges and pledges compliance with 709.92(b) which stipulates that treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. In order to correct this deficiency, the records software will be programmed to post an email reminder to the counselor 5 days before (day 55) upcoming treatment plan updates are due. Additionally, a spreadsheet will be created by each counselor tracking the due dates of each chart. The treatment plan of every active client will be reviewed and updated in consultation with another staff member on or before day 60 of the current plan or update. In the event a client has not attended for 30 days of the treatment plan term, or has cancelled without reason, the case will be closed with pertinent closing notice and summary. The application of this Plan of Correction is the responsibility of the Director. This POC is in effect as of January 2, 2025. |
Observations
Based on a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in six of seven client records reviewed.Client #1 was admitted on February 16, 2024 and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on February 23, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks of March 24, 2024 through March 30, 2024, April 7, 2024 through April 13, 2024, April 28, 2024 through May 4, 2024, May 12, 2024 through May 18, 2024, May 26, 2024 through June 1, 2024, September 1, 2024 through September 7, 2024 and September 15, 2024 through September 21, 2024. Additionally, there were no individual counseling sessions documented in the client record for the months of June, July, August, October and November 2024.Client #2 was admitted on March 15, 2024 and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on March 15, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks of April 7, 2024 through April 13, 2024, May 5, 2024 through May 11, 2024, May 30, 2024 through June 6, 2024, July 21, through July 27, 2024, August 4, 2024 through August 10, 2024, August 18, 2024 through August 24, 2024, September 1, 2024 through September 7, 2024, September 15, 2024 through September 21, 2024, September 29, 2024 through October 5, 2024, October 6, 2024 through October 12, 2024 and October 20, 2024 through October 26, 2024. Additionally, there were no individual counseling sessions documented in the client record for the month of November 2024.Client #3 was admitted on February 16, 2024 and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on February 16, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks of February 18, 2024 through February 24, 2024, February 25, 2024 through March 2, 2024, March 30, 2024 through April 6, 2024, June 9, 2024 through June 15, 2024, June 16, 2024 through June 22, 2024, August 11, 2024 through August 17, 2024, September 8, 2024 through September 14, 2024, September 15, 2024 through September 21, 2024, September 22, 2024 through September 28, 2024, September 29, 2024 through October 5, 2024, October 6, 2024 through October 12, 2024, October 20, 2024 through October 26, 2024. Additionally, there were no individual counseling sessions documented in the client record for the months of March or November 2024. Client #4 was admitted on December 8, 2023, and was discharged on April 26, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on December 8, 2023, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks of December 24, 2024 through December 30, 2024, February 4, 2024 through February 10, 2024, February 11, 2024 through February 17, 2024, March 10, 2024 through March 16, 2024 and April 7, 2024 through April 13, 2024. Additionally, there were no individual counseling sessions documented in the client record for the month of January 2024.Client #5 was admitted on May 22, 2024, and was discharged on September 2, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on May 22, 2024, indicated that the client was to receive two individual counseling session per month; however, there were no individual counseling session documented in the client record for the month of August 2024. Client #7 was admitted on March 27, 2024, and was discharged on November 15, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on March 29, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks April 7, 2024 through April 13, 2024, May 19, 2024 through May 25, 2024, May 26, 2024 through June 1, 2024, June 2, 2024 through June 8, 2024, June 30, 2024 through July 6, 2024, July 21, 2024 through July 27, 2024, August 25, 2024 through August 31, 2024 and September 15, 2024 through September 21, 2024. Additionally, there were no individual counseling sessions documented in the client record for the month of October 2024.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Brighter Visions Counseling acknowledges and pledges compliance with 709.92(c) which stipulates that counseling services are provided according to the individual treatment and rehabilitation plan. The client record will list all dates of service, cancellations, and no-showed appointments to document that the planned interval of service is being practiced. This Plan of Correction is in place on December 15, 2024. The implementation of this POC is the responsibility of the Director. |