Observations
Based on a review of patient records, the facility failed to document group session progress notes. The missing documentation was for a Relapse Prevention Group on March 11, 2022, and three Meditation Groups held on July 28, 2021, April 28, 2021 and April 14, 2021.
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Plan of Correction
Counseling staff will continue to document any and all Pt. related engagements as per §709.93(a)(5) at the completion of each unique session. For Pt.'s who do not attend to the counseling session for the appropriate amount of time, counseling staff will no longer write a 'General Note' for such, yet will be trained to write an appropriately titled notation (i.e. Individual and/or Group) for the session, documenting Pt.'s attendance, however listing the shorter time duration and ensure that such a note is set appropriately so as to not generate a compensable service.
The reviewed records do have 'General Notes' listed for the group session(s) in question and would not provide an easy guide to the documentation, in fact, being completed for those who did not attend for the entire session.
Clinical Supervisor will monitor note completion daily.
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