Observations
Based on the review of patient records, the facility failed to document that each patient was provided at least 1 hour per month of group or individual psychotherapy every two months in one of two patient records.
The findings include:
Fourteen patient records were reviewed on January 26-27, 2015. Two patient records reviewed required at least 1 hour per month of group or individual psychotherapy every two months. Patient record # 8 did not document the required hours.
Patient # 8 was admitted on February 2, 2009 and required least 1 hour of group or individual psychotherapy every 2 months. There were no documented psychotherapy hours for the months of October, November and December, 2014.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clients will receive the required psychotherapy hours according to regulation and treatment plan.
Counselors were retrained on the requirements on 1.28.15 by the program manager during staff meeting.
Client charts will be randomly audited, monthly for accuracy through peer chart reviews. Program manager will review results with counselors during monthly supervision.
Further, counselors will continue to maintain a monthly tracking grid identifying therapy hours required for each client. Grid will be randomly checked by program manager monthly for completion. |