Observations
Based on a review of client records and the facility policy and procedure manual the facility failed to document progress notes in eight client records.
The findings include:
Seventeen client records were reviewed on October 22 through 23, 2009. According to the facility's policy and procedure manual, policy number 709.93 Section A, sub section 5, "There is to be progress note anytime services are provided by individual, family session, group session, etc. This note is to be signed by whoever provided the service. The types of information in these notes will be data, assessment, and plans relative toward treatment. The D.A.P. format is to be used where: D- data from the session- The data will include information presented by the client during the counseling session, counselor observations and information about the client from other sources. A- Assessment - the assessment is the interpretative statement(s) based upon both new and previous information and includes the counselor's analysis of and conclusion regarding the client's current situation or status. P- Plan- The plan will reflect the counselor's actions to be taken in light of the evaluation and indicate the direction of treatment and include action steps, counselor plans and client assignments or tasks." Progress notes were required in seventeen client records. The facility did not document the clinician's assessment and plan of each client for individual counseling progress notes in client records #1, 3, 7, 8, 10, 14, 15, and 16. The facility failed to consistently use the Data, Assessment, and Plan format.
Record # 1 failed to document all individual progress notes in D. A. P. format.
Record # 3 failed to document individual counseling progress notes in D. A. P. format for the individual sessions on the following dates:
6/23/2009, 6/24/2009, 6/30/2009, 7/1/2009, 7/2/2009, 7/7/2009, 7/9/2009, 7/14/2009, 7/15/2009, 7/16/2009, 7/16/2009, 7/21/2009, 7/22/2009, 7/23/2009, 7/28/2009, 7/29/2009, 7/30/2009, 8/4/2009, 8/5/2009, 8/6/2009, 8/13/2009, 8/19/2009, 9/3/2009, 9/16/2009, 9/22/2009, and 9/28/2009.
Record # 7 failed to document individual counseling progress notes in D. A. P. format for the individual session on 8/2/2009. The clinician failed to document an assessment and plan.
Record # 8 failed to document individual progress notes in D. A. P. format for the individual sessions on the following dates:
6/23/2009, 2/24/2009, 6/30/2009, 7/1/2009, 7/14/2009, 7/15/2009, 7/16/2009, 7/21/2009, 7/22/2009, 7/23/2009, 7/28/2009, 7/29/2009, 7/30/2009, 8/4/2009, 8/5/2009, 8/6/2009, 8/13/2009, 8/19/2009, 9/3/2009, 9/16/2009, 9/22/2009, and 9/28/2009.
Record # 10 failed to document individual counseling progress notes in D. A. P. format for the individual counseling sessions on the following dates:
6/19/2009, 6/25/2009, 7/2/2009, 7/9/2009, 7/23/2009, 7/30/2009, 9/16/2009, 9/23/2009, 10/6/2009, and 10/12/2009.
Record # 14 failed to document individual counseling progress notes in D. A. P. format for the individual sessions on 7/7/2009 and 7/20/2009. The clinician failed to document an assessment and plan.
Record # 15 failed to document individual counseling progress notes in D. A. P. format.
Record # 16 failed to document individual counseling progress notes in D. A. P. format for the individual counseling session on 10/17/2008.
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Plan of Correction
All clinical staff participated in a training on the utilization of D.A.P. format in documenting progress notes on 10/27/09. all staff were advised that from 10/27/09 forward data, assessment, and plan must be clearly indicated on all progress notes. The use of DAP format has been added to the chart monitoring form and will be reviewed weekly in peer reviews by clinical staff, and monthly by the Program Director during chart monitoring. |