Observations
Based on a review of client records during the complaint investigation on February 27, 2024, the facility failed to document the client's treatment plan in 1 of 4 client records reviewed.Client #2 - Admit date: 2/19/24 (patient moved to rehab on 2/22/24)2/23/24 - note stated that a treatment plan was developed, but the treatment plan wasn ' t documented in the client ' s record.
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Plan of Correction
All treatment plans will be created in a timely manner. Initial treatment plan will be created by nursing staff at time of admission. Counseling staff will add to initial treatment to include counseling goals, objectives and strengths within seven days with patient signature of approval. Treatment plans will be monitored via audit on a monthly basis. |
Observations
Based on a review of 4 client records on February 27, 2024, the facility failed to document individual group notes, or the notes were combined in 4 of 4 client records reviewed. Client #1 - Admit date: 2/3/24 started detox and then moved to rehab on 2/6/24.2/5/2024 through 2/9/2024 the note stated that the client attended small groups that centered around surrender, codependency, guilt, shame and forgiveness. Client #2 - Admit date: 2/19/24 (patient moved to rehab on 2/22/24)2/23/24 group note - only stated that the client attended group. No documentation of what the group was about, the assessment of the client and plan.2/26/24 group notes - only stated that the client attended group. No documentation of what the group was about, the assessment of the client and plan.Client #3 - Admit date: 1/31/24(detox) moved to rehab on 2/3/242/6/24 and 2/13/2024 group notes - only stated that the client attended group. No documentation of what the groups were about, the assessment of the client and plan.2/7/2024 note for groups 2/2/2024, 2/5/2024 and 2/7/2024 through 2/9/2024 the notes stated that the client attended groups, but no documentation of what the groups were about.2/14/24 note for groups - groups 2/9/2024, 2/12/2024 and 2/14/2024 the notes stated that the client attended groups, but no documentation of what the groups were about.2/15/24 group note - only stated that the client attended group. No documentation of what the group was about, the assessment of the client and plan.2/16/2024, 2/19/2024 and 2/21/2024 one group note - Not sure if it was one group focusing on one topic or several groups with different topics.Client #4 - Admit date: 1/27/24 detox, 1/28/24 moved to rehabGroup notes - 2/2/24, 2/10/24, 2/21/24, 2/23/2024, 2/26/2024 and 2/27/2024 stated client only participated.2/7/2024, 2/12/2024, 2/13/2024, 2/14/2024, 2/16/2024, 2/17/2024 group notes - only stated that the client attended group. No documentation of what the groups were about, the assessment of the client and plan.2/19/24 groups note for the week: 2/12, 2/14 and 2/16 - plan is client will participate in three groups by 2/23/24.2/22/24 - counseling note stated that the client participated in a grief group and no plan was documented. 2/26/24 - individual group therapy note - talked about three groups on one note for groups 2/19/2024, 2/21/2024 and 2/23/2024. It appears that there were three different groups discussed in this group note.
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Plan of Correction
Counselors will complete individual group DAP notes for each small group therapy session to include identified areas of group topic, assessment and plan. Management will complete monthly audits or charts to assess for compliance. |