Cherron's Argument

Counselor red flagged pt. and requested that he meet for brief TX intervention to discuss his current counseling non-compliance status and explaining the risk of discharge from the program if he fails to do an individual session by 1/22/17. AMS receptionist told this writer that pt. is asking why he needs to meet with this writer. This writer told him to inform him that if he fails to complete one hour individual session by 1/22/17 he will be subject for a TX discharge. Pt. refused to meet with this writer and he failed to schedule an individual session on the above date.

3. The patient had informed this writer initially of his goals of wanting to return back to the Hartford Dispensary due to the length of time he has been with the clinic and his positive rapport with his prior counselor at the other facility. The patient was compliant with his individual sessions with this writer and provided cancellation if unable to attend the session in the meantime while he awaits on the process of completion with his intake at Hartford Dispensary.

Frankie Tilmon continues to be out of treatment compliance. Frankie has missed his last four appointments, 7/2/15, 7/9/15, 7/16/15, and 7/30/15. Frankie contacted this provider on 7/6 to apologize for missing his appointment on 7/2 and was reminded of his next appointment on 7/9, which he agreed to attend. On 7/15 Frankie contacted this provider to apologize for missing his treatment appointment on 7/9 and agreed to make his appointment the following day, which he failed to appear for. On 7/16 Frankie contacted this provider to again apologize for missing his appointment and wanted to confirm his next scheduled appointment day/time. I told Frankie that his appointment day and time has not changed; it was on Thursdays at 4pm. Frankie told

D-Met with the patient as she placed on HOLD due to recent concern of her overall well-being reported by Nurse Frank as he reported to this writer yesterday of his concerns that the patient's boyfriend is refusing her to increase on her methadone due to an agreement and the patient tends to appear emotional. Upon meeting with the patient, the patient immediately knew why she is meeting with her and started to get emotional. Denies feeling SI/HI. According to the patient, she had an agreement with her boyfriend of which she agreed to increase her dose up to 55mgs as her boyfriend will closely monitor her recovery. The patient does not feel unsafe around her boyfriend as she reported. This writer strongly advised the patient that she has rights to her own recovery process because it's her in the recovery and seeking treatment, at which the patient agreed. But says, "I am fine with my current

Met with the patient as directed by the Clinical Director. According to the patient, he requested for a dose decrease of 1mgs per day until he reaches 0mgs. Based on the patient's order, he is indeed decreasing his methadone of 1mgs; however, the order stated that it will stop at 53mgs, not 0mgs. The patient informed this writer about a discussion he had with his assigned counselor Cherron about the importance of this due to the need to get off on the methadone as he wants to obtain his CDL but cannot do so if he is prescribed with methadone. This writer reviewed the patient's record and there are no AMA taper signed and no medical consultation documented. This writer then addresses this matter with the clinic's medical doctor, who was told

First, we will examine my initial clinical note on 8/15/16 with client, Rhonda Smith, session one. During this first session, I collected Rhonda’s demographic and intake information (Murphy & Dillon, 2015; Reamer, 2001). This included a signed consent for treatment, which we reviewed and all her questions were answered, as well as signed medical releases for previous therapy and agency records, i.e., DVIS, CPS, CASA, that will be requested (Murphy & Dillon, 2015; Reamer, 2001). Additionally, she was informed about HIPAA, patient privacy rights, billing practices, professional boundaries and expectations, and how to contact me during business hours, and after-hours crisis lines, and on-call assistance phone numbers for resources if it is outside of my business hours (Murphy & Dillon, 2015).

The patient was not pleased with the new and again, he was emotional. This writer provided a explanation as to why this is occurring due to this writer current position. However, in the event, should the patient needs an assistance he can request to see this

She informed the writer "someone" applied for housing for her at the Owensboro housing authority. Writer spoke to her about a mental health provider. She informed the writer she sees Dr. Silva and has not been since December/January. Writer asked pt. if she wanted to schedule an appointment with RVBH to see the psychologist. Writer explained the process of attending a therapist before scheduling with the psychologist. RVBH scheduling department did not answer. She wanted to call RVBH back on Thursday.

D-Met with the patient to discuss her Aruba trips. This writer advised the patient that this writer is making contact with some staff members at the hospital, but was unable to speak to someone from the psychiatry department due to the hours as there is a 2 hour difference. The patient appeared to cheerful to learn that this writer is moving her host application forward. According to the patient, she apologized about her behavior yesterday and says, " Bobby was on me like why your counselor is not doing anything. My counselor did this and that.....it's frustrate me." This writer informed the patient that this clinic did not ignore her request whereas this writer was aware of it a month ago, but there was barriers to the patient dose as she

On July 2, 2015, the CP left a message at 11:41 a.m. regarding the missed intake appointment. She stated that she did not know the appointment time, the date of her last appointment, and her address changed. On July 6, 2015, the intake supervisor returned a telephone call to the CP; a left voicemail for the CP at 8:00 a.m. regarding an appointment rescheduled for August 3, 2015. On July 16, 2015, a letter was mailed to the CP for an intake appointment on August 3, 2015. On July 30, 2015, the intake supervisor received a telephone call from the CP regarding verification that she was at work on May 5, 2015. The CP was advised that the only information received from her was the Report/Request Form on May 28, 2015. The CP stated that she turned in a letter from her employer in June. The intake supervisor discussed with the CP that she had missed two intake appointments. The CP stated she would turn in documentation from her employer regarding the two missed appointments. The CP stated she did not know of the July 1, 2015 appointment. The intake supervisor asked the CP about her mailing address. The CP stated that she was staying at the Avon Street address and

The patient than asked the patient about his social security if he has been completed yet and this writer advised the patient that it is still pending at the

Pt. failed to attend his scheduled counseling session on Monday, 12/12/16 at 7:00 am Patient showed up after dosing (8:24 am) reporting that he was unable to keep his appointment for today because he got an emergency. Pt. reported that he cant stay because he needs to go to work but he rescheduled his counseling session with this writer for Wednesday, 12/14/16 at 7:00

D-The patient arrived on time for his appointment. Reported stable on his dose and denies the need for a dose increase or decrease. According to the patient, he called Wheeler Clinic and did not get a return phone call after he left a message on their general mailbox. So, this writer took the liberty to call Wheeler Clinic alongside with the patient. According to the representative, there could have been a high volume of calls last week; however, the clinic does not schedule appointments for the I.O.P., it's a walk in from Monday thru Thursday from 10-5:30pm and Fridays from 9:3;30pm. The patient is planning to do the walk-in to Wheeler Clinic and will update this writer tomorrow during another counseling session of his enrollment at the IOP.

D-During the course of the session, the patient appears to be anxious because she cannot make reasonable decision about her treatment whereas the patient expressed she wants to decrease on her dose, even though a dose change request was completed on 03/02/2016 and hasn't been approved. This writer addressed with the patient about the program policy. Furthermore, the patient appears to be ignored by this writer when she addressed about obtaining take home bottles/special bottles if she's unable to come to the clinic and this writer informed the patient about the take home policy/procedure, including special bottle. In addition, the patient is uncertain if she has gotten the full time position as she is currently awaiting on the status today

Supervisor met with Michael to further trained him about the clinic’s expectation of his “Services Due by Counselor.” Please note, this writer reviewed Michael’s services staff detail from 03/1/2013-03/7/2013. This writer informed Michael about the need to document patient’s who are a “no show, rescheduled, and/or cancellation” for documentation. It is very common for a new counselor during their first 90 days to make such common errors. In addition, Michael was advised to be mindful of his start time and end time to avoid any over lapse with billable issues, i.e. if a session end at 8:35am, the next session should start at 8:36 am. Furthermore, this writer addressed with Michael about his aftercare discharge plan and his treatment plans.