Day One

Deficiency cited, biennial survey : SECTION 8. COMPREHENSIVE CLIENT ASSESSMENT C. Comprehensive assessment. 1.c. Medical domain, including but not limited to physical health, current medications ...

Based on review of client Comprehensive Assessments and interview with the Program Administrator, Day One failed to include physical and environmental barriers to treatment, in the Comprehensive Assessments in 4 out of 4 active Substance Use Disorder client records reviewed, (Clients #1-#4). Finding: On 08/06/2026 Surveyor reviewed 4 active Substance Use Disorder client records, (Clients #1-#4). Clients #1-#4's Comprehensive Assessments failed to contain evidence of physical and environmental barriers to treatment. This finding was confirmed with the Program Administrator on 08/06/2026 at approx. 2:30pm, and again at the Exit Conference with the Program Administrator on 08/06/2026 at approx. 3:00pm.

Deficiency cited, biennial survey : SECTION 8. COMPREHENSIVE CLIENT ASSESSMENT C. Comprehensive assessment. 2. In a comprehensive assessment for clients with substance use, the documentation must ...

Based on review of client Comprehensive Assessments and interview with the Program Administrator, Day One failed to age of onset of alcohol and drug use; and duration, in the Comprehensive Assessments in 1 out of 4 active Substance Use Disorder client records reviewed, (Client #1). Finding: On 08/06/2026 Surveyor reviewed 4 active Substance Use Disorder client records, (Clients #1-#4). Client #1's Comprehensive Assessment failed to include the age of onset of alcohol and drug use; and duration. This finding was confirmed with the Program Administrator on 08/06/2026 at approx. 2:30pm, and again at the Exit Conference with the Program Administrator on 08/06/2026 at approx. 3:00pm.

Deficiency cited, biennial survey : SECTION 8. COMPREHENSIVE CLIENT ASSESSMENT C. Comprehensive assessment. 4. The comprehensive assessment must be signed, credentialed, and dated by the person ...

Based on review of client Comprehensive Assessments and interview with the Program Administrator, Day One failed to include the recommended ASAM level of care, in the Comprehensive Assessments in 4 out of 4 active Substance Use Disorder client records reviewed, (Clients #1-#4). Finding: On 08/06/2026 Surveyor reviewed 4 active Substance Use Disorder client records, (Clients #1-#4). Clients #1-#4's Comprehensive Assessments failed to include the recommended ASAM level of care based on the criteria met by the clients. This finding was confirmed with the Program Administrator on 08/06/2026 at approx. 2:30pm, and again at the Exit Conference with the Program Administrator on 08/06/2026 at approx. 3:00pm.

Deficiency cited, biennial survey : SECTION 8. COMPREHENSIVE CLIENT ASSESSMENT D. Updating assessment. A client's comprehensive assessment must be updated at least annually and when there is a ...

Based on review of client Comprehensive Assessments and interview with the Program Administrator, Day One failed to annually update the Comprehensive Assessments in 2 out of 4 active Substance Use Disorder client records reviewed, (Clients #3&#4). Finding: On 08/06/2026 Surveyor reviewed 4 active Substance Use Disorder client records, (Clients #1-#4). Clients #3&#4's records failed to include an annually updated Comprehensive Assessment. This finding was confirmed with the Program Administrator on 08/06/2026 at approx. 2:30pm, and again at the Exit Conference with the Program Administrator on 08/06/2026 at approx. 3:00pm.

Deficiency cited, biennial survey : SECTION 9. CLIENT SERVICE PLAN H. Service plan. 2. b. The methods and frequency of services and supports to be provided by the organization.

Based on review of client Service Plans and interview with the Program Administrator, Day One failed to identify the evidence-based methods and frequency of services and supports to be provided by the organization in the Service Plans in 3 out of 4 active Substance Use Disorder client records reviewed, (Clients #1, #3 & #4). Finding: On 08/06/2026 Surveyor reviewed 4 active Substance Use Disorder client records, (Clients #1-#4). Clients #1, #3 & #4 Service Plans failed to identify the evidence- based methods and frequency of services and supports to be provided by the organization. This finding was confirmed with the Program Administrator on 08/06/2026 at approx. 2:30pm, and again at the Exit Conference with the Program Administrator on 08/06/2026 at approx. 3:00pm.

Deficiency cited, biennial survey : SECTION 9. CLIENT SERVICE PLAN H. Service plan. 2.e. The role of the client's family and natural support system, as appropriate, in the client's treatment and ...

Based on review of client Service Plans and interview with the Program Administrator, Day One failed to identify the role of the client's family and natural support system, as appropriate, in the client's treatment and recovery in the Service Plans in 3 out of 4 active Substance Use Disorder client records reviewed, (Clients #1, #3 & #4). Finding: On 08/06/2026 Surveyor reviewed 4 active Substance Use Disorder client records, (Clients #1-#4). Clients #1, #3 & #4 Service Plans failed to identify the role of the client's family and natural support system, as appropriate, in the client's treatment and recovery. This finding was confirmed with the Program Administrator on 08/06/2026 at approx. 2:30pm, and again at the Exit Conference with the Program Administrator on 08/06/2026 at approx. 3:00pm.

Deficiency cited, biennial survey : SECTION 9. CLIENT SERVICE PLAN K. Periodic review and update of service plan. 1. Service plans must be reviewed at least every 90 days, unless otherwise ...

Based on review of client Service Plans and interview with the Program Administrator, Day One failed to update the Service Plans every 90-days in 3 out of 4 active Substance Use Disorder client records reviewed, (Clients #1, #3 & #4). Finding: On 08/06/2026 Surveyor reviewed 4 active Substance Use Disorder client records, (Clients #1-#4). Clients #1, #3 & #4 Service Plans were not reviewed and updated every 90-days. Client #1 had a timely initial Service Plan, a timely first 90-day review and a current Service Plan (4th 90-day review), but was missing a 2nd and 3rd 90-day review. Client #3 had a timely initial Service Plan, and timely 90-day reviews for the first 3 cycles. Client #3 was missing 90-day reviews for 3 cycles, the 4th, 5th, 6th 90-day review cycles. Client #3 has a current Service Plan. Client #4 had a timely initial Service Plan, and has a current Service Plan, but was missing all 90-day reviews in between for 4 cycles, 1st, 2nd, 3rd, and 4th. This finding was confirmed with the Program Administrator on 08/06/2026 at approx. 2:30pm, and again at the Exit Conference with the Program Administrator on 08/06/2026 at approx. 3:00pm.

Deficiency cited, biennial survey : SECTION 13. PERSONNEL I. Orientation and training. 1. The organization must have a written plan for the orientation and training of personnel that is reviewed ...

Based on review of Day One's Orientation and Training Plan, and interview with the Program Administrator, Day One failed to document an annual review date. Finding: On 08/06/2026 Surveyor reviewed Day One's Orientation and Training Plan. The plan was dated revised on 10/29/2024, there was no evidence of an annual review and update for 10/29/2025 or after. This finding was confirmed with the Program Administrator on 08/06/2026 at approx. 10:00am, and again at the Exit Conference with the Program Administrator on 08/06/2026 at approx. 3:00pm.

Deficiency cited, biennial survey : SECTION 8. COMPREHENSIVE CLIENT ASSESSMENT C. Comprehensive assessment. 1.c. Medical domain, including but not limited to physical health, current medications ...

Based on review of client Comprehensive Assessments and interview with the Program Administrator, Day One failed to include physical and environmental barriers to treatment, in the Comprehensive Assessments in 4 out of 4 active Mental Health client records reviewed, (Clients #1-#4). Finding: On 08/06/2026 Surveyor reviewed 4 active Mental Health client records, (Clients #1-#4). Clients #1-#4's Comprehensive Assessments failed to contain evidence of physical and environmental barriers to treatment. This finding was confirmed with the Program Administrator on 08/06/2026 at approx. 1:00pm, and again at the Exit Conference with the Program Administrator on 08/06/2026 at approx. 3:00pm.

Deficiency cited, biennial survey : SECTION 9. CLIENT SERVICE PLAN H. Service plan. 1. The client's service plan must be based on needs identified during the assessment process and completed ...

Based on review of client Service Plans and interview with the Program Administrator, Day One failed to complete a Service Plan within 30 days of admission in 1 out of 4 active Mental Health client records reviewed, (Client #4). Finding: On 08/06/2026 Surveyor reviewed 4 active Mental Health client records, (Clients #1-#4). Client 4's initial Service Plan was not signed by the client or guardian until 73 days past the 30-day requirement. This finding was confirmed with the Program Administrator on 08/06/2026 at approx. 1:00pm, and again at the Exit Conference with the Program Administrator on 08/06/2026 at approx. 3:00pm.

Deficiency cited, biennial survey : SECTION 9. CLIENT SERVICE PLAN H. Service plan. 2. b. The methods and frequency of services and supports to be provided by the organization.

Based on review of client Service Plans and interview with the Program Administrator, Day One failed to identify the evidence-based methods and frequency of services and supports to be provided by the organization in the Service Plans in 4 out of 4 active Mental Health client records reviewed, (Clients #1-#4). Finding: On 08/06/2026 Surveyor reviewed 4 active Mental Health client records, (Clients #1-#4). Clients #1-#4's Service Plans failed to identify the evidence-based methods and frequency of services and supports to be provided by the organization. This finding was confirmed with the Program Administrator on 08/06/2026 at approx. 1:00pm, and again at the Exit Conference with the Program Administrator on 08/06/2026 at approx. 3:00pm.

Deficiency cited, biennial survey : SECTION 9. CLIENT SERVICE PLAN H. Service plan. 2.e. The role of the client's family and natural support system, as appropriate, in the client's treatment and ...

Based on review of client Service Plans and interview with the Program Administrator, Day One failed to identify the role of the client's family and natural support system, as appropriate, in the client's treatment and recovery in the Service Plans in 4 out of 4 active Mental Health client records reviewed, (Clients #1-#4). Finding: On 08/06/2026 Surveyor reviewed 4 active Mental Health client records, (Clients #1-#4). Clients #1-#4's Service Plans failed to identify the role of the client's family and natural support system, as appropriate, in the client's treatment and recovery This finding was confirmed with the Program Administrator on 08/06/2026 at approx. 1:00pm, and again at the Exit Conference with the Program Administrator on 08/06/2026 at approx. 3:00pm.

Deficiency cited, biennial survey : SECTION 13. PERSONNEL I. J. Orientation and training. 1. The organization must have a written plan for the orientation and training of personnel that is ...

Based on review of Day One's Orientation and Training Plan, and interview with the Program Administrator, Day One failed to document an annual review date. Finding: On 08/06/2026 Surveyor reviewed Day One's Orientation and Training Plan. The plan was dated revised on 10/29/2024, there was no evidence of an annual review and update for 10/29/2025 or after. This finding was confirmed with the Program Administrator on 08/06/2026 at approx. 10:00am, and again at the Exit Conference with the Program Administrator on 08/06/2026 at approx. 3:00pm.