Observations
Based on a review of nine client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in four records reviewed.
Client #1 was admitted on February 23, 2023 and was discharged on May 16, 2023. The record contained a consent to release information form to the funding source that was signed and dated February 23, 2023, by the witness, that was missing the dated signature of the client.
Client #4 was admitted on November 17, 2022 and was discharged on June 15, 2023. The record contained a consent to release information form to the funding source that was signed and dated November 17, 2022, by the witness, that was missing the dated signature of the client.
Client #8 was admitted on December 28, 2022 and was discharged on February 3, 2023. The record contained a consent to release information form to the funding source that was signed and dated December 28, 2022, by the witness, that was missing the dated signature of the client.
Client #9 was admitted on March 17, 2023 and was discharged on June 13, 2023. The record contained a consent to release information form to the funding source that was signed and dated March 17, 2023, by the witness, that was missing the dated signature of the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will assure that clients consent to release of information through signed and dated signature before information is released. Counselors will not proceed with admission and/or treatment and/or release of information until after signed and dated client consent is obtained. This policy will be included in the facility's standard operating manual and all staff will acknowledge receipt and understanding in writing. To be completed by 7/31/23 |
Observations
Based on a review of nine client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client in four of five applicable records reviewed.
Client #1 was admitted on February 23, 2023 and was discharged on May 16, 2023. The record contained no documentation that the individual treatment and rehabilitation plan completed on March 23, 2023 was completed with the client.
Client #4 was admitted on November 17, 2022 and was discharged on June 15, 2023. The record contained no documentation that the individual treatment and rehabilitation plan completed on December 17, 2022 was completed with the client.
Client #6 was admitted on December 16, 2022 and was active at the time of the inspection. The record contained no documentation that the individual treatment and rehabilitation plan completed on January 6, 2023 was completed with the client.
Client #9 was admitted on March 17, 2023 and was discharged on June 13, 2023. The record contained no documentation that the individual treatment and rehabilitation plan completed on April 4, 2023 was completed with the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will assure that all treatment plans are developed with the client. Counselors will be required to obtain dated client signature on all treatment plans. The Executive Director will conduct bi-weekly review of all clinical records to assure that this policy is being adhered to. Treatment plans that do not meet this policy will be voided and the counselor will be required to immediately meet with the client to develop a plan that is signed by the client. Counselors that do not follow this procedure will be subject to disciplinary action. Counselors will acknowledge receipt and understanding of this policy through written signature. |
Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in five of nine records reviewed.
Client # 2 was admitted on June 8, 2022 and was discharged on December 1, 2022. The treatment plans completed on June 22, 2022, August 17, 2022, and October 13, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between July 27, 2022, and August 24, 2022, or the weeks of September 12, 2022, September 26, 2022, October 31, 2022, and November 14, 2023.
Client # 3 was admitted on March 17, 2022 and was discharged on November 29, 2022. The treatment plans completed on August 16, 2022, and October 16, 2022, indicated that the client was to receive one individual session per week; however, there was no documentation of an individual session between August 26, 2022, and September 13, 2022, or between October 18, 2022 and November 10, 2022.
Client # 4 was admitted on November 17, 2022 and was discharged on June 15, 2023. The treatment plans completed on February 17, 2023, and April 17, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between February 28, 2023, and March 22, 2023, or between April 5, 2023, and April 21, 2023, between April 21, 2023 and May 12, 2023, or between May 12, 2023 and May 26, 2023.
Client # 6 was admitted on December 16, 2022 and was active at the time of the inspection. The treatment plans completed on January 6, 2023, and March 6, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between January 26, 2023, and February 17, 2023, or between March 7, 2023 and March 21, 2023.
Client # 7 was admitted on April 19, 2022 and was active at the time of the inspection. The treatment plans completed on August 16, 2022, December 6, 2022, and February 6, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between August 30, 2022 and September 13, 2022, between November 29, 2022 and December 20, 2022, between December 20, 2022 and January 10, 2023, and only one session between January 24, 2023 and March 21, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will assure that counseling services are provided according to individual treatment plans. Counselors will enter a notation on the client attendance record for each date where there is a missed appointment/absence of a session scheduled as per the treatment plan. Counselors will acknowledge receipt and understanding of this policy through written and signed statement. |