Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed at intake and every 60 days following admission.Client #2 was admitted on April 6, 2026 and was still active at the time of the inspection. A case consultation was completed on April 6, 2026 and the next consultation was due no later than Jume 6, 2026; however, none was completed.Client #4 was admitted on July 17, 2024 and was discharged on November 26, 2025. A case consultation was completed on August 1, 2025 and the next case consultation was due no later than October 1, 2025; however, it was not completed until November 26, 2025.Client #5 was admitted on February 25, 2026 and was discharged on May 15, 2026. A case consultation was completed on February 25, 2026 and the next case consultation was due no later than April 27, 2026; however, it was not completed until May 15, 2026.Client #7 was admitted on November 21, 2024 and was discharged on January 8, 2026. A case consultation was completed on September 17, 2025 and the next case consultation was due no later than November 17, 2025; however, it was not completed until January 7, 2026.These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the August 14, 2025 licensing inspection.
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Plan of Correction
A Documented review of 709.93(a)(8)
will be completed with treatment
staff by 8/31/2026. To ensure
ongoing compliance with, 709.93(a)
(8) a monthly audit will be conducted
by the primary counselor in conjunction with the Facility Director to monitor the completion of case consultation notes every 60-days following admission in
accordance with the facilities policy
and procedure manual. |