Observations
Based on a review of client records, the facility failed to document the provision of treatment services consistent with the type and frequency specified in the treatment plan in five of ten client records reviewed.
The findings included:
Ten client records were reviewed on May 20, 2014. Six records were reviewed for documentation of the provision of services in accordance with those specified in the treatment plan. Services were not documented as stated in the treatment plans in client records # 1, 2, 3, 4 and 5.
Client # 1 was admitted on February 26, 2014 and their last session was on May 14, 2014. The comprehensive treatment plan was developed on February 26, 2014 and a treatment plan update was developed on April 16, 2014. Each treatment plan identified individual and group sessions to be provided on a weekly basis. Client # 1 did not attend individual sessions during the following weeks: March 2-8, 2014 and April 6-14, 2014. Additionally, client # 1 did not attend group sessions during the following weeks: March 2-, 2014, March 9-15, 2014, March 16-22, 2014, March 23-29, 2014, April 6-12, 2014, April 20-26, 2014, April 27-30, 2014, May 1-3, 2014 and May 4-10, 2014. There was no other documentation included in the record stating why the client failed to attend individual and group sessions as stipulated on their treatment plans.
Client # 2 was admitted on February 27, 2014 and their last session was on May 16, 2014. The comprehensive treatment plan was developed on March 28, 2014 and identified individual and group sessions to be provided on a weekly basis. Client # 2 did not attend individual sessions during the following weeks: April 6-12, 2014, April 20-26, 2014, April 27-30, 2014, May 1-3, 2014 and May 4-10, 2014. Additionally, client # 2 did not attend group sessions during the following weeks: April 20-26, 2014, April 27-30, 2014, May 1-3, 2014 and May 4-10, 2014. There was no other documentation included in the record stating why the client failed to attend individual and group sessions as stipulated on their treatment plans.
Client # 3 was admitted on February 11, 2014 and their last session was on April 23, 2014. The comprehensive treatment plan was developed on February 12, 2014 and a treatment plan update was developed on April 01, 2014. Each treatment plan identified individual and group sessions to be provided on a weekly basis. Client # 3 did not attend individual sessions during the following weeks: February 16-22, 2014, February 23-28, 2014, March 1, 2014, March 2-8, 2014, April 6-12, 2014, April 13-19, 2014, April 27-30, 2014, May 1-3, 2014 and May 11-17, 2014. Additionally, client # 3 did not attend group sessions during the following weeks: February 16-22, 2014, February 23-28, 2014, March 1, 2014, March 2-8, 2018, March 16-22, 2014, March 23-29, 2014, April 13-19, 2014, April 27-30, May 1-3, 2014, May 4-10, 2014 and May 11-17, 2014. There was no other documentation included in the record stating why the client failed to attend individual and group sessions as stipulated on their treatment plans.
Client # 4 was admitted on February 12, 2014 and their last session was on May 13, 2014. The comprehensive treatment plan was developed on March 14, 2014 and a treatment plan update was developed on April 17, 2014. Each treatment plan identified individual and group sessions to be provided on a weekly basis. Client # 4 did not attend individual sessions during the following weeks: April 13-19, 2014, April 20-26, 2014, May 4-10, 2014 and May 11-17, 2014. Additionally, the facility failed to document any group sessions. There was no other documentation included in the record stating why the client failed to attend individual and group sessions as stipulated on their treatment plans.
Client # 5 was admitted on April 8, 2014 and their last session was on May 12, 2014. The comprehensive treatment plan was developed on April 25, 2014 and a treatment plan update was developed on May 7, 2014. Each treatment plan identified individual and group sessions to be provided on a weekly basis. Client # 5 did not attend their individual session during the following week: May 4-10, 2014. Additionally, client # 5 did not attend group sessions during the following weeks: May 4-10, 2014 and May 11-17, 2014. There was no other documentation included in the record stating why the client failed to attend individual and group sessions as stipulated on their treatment plans.
The findings were reviewed and confirmed with the facility director.
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Plan of Correction
A clinical meeting will be held on July 1, 2014 by the Clinical Supervisor with the MCMC clinical staff to address standard 709.92 and the necessity to provide counseling services according to the individual treatment and rehabilition plan set forth with the patient. The proper documentation of these provided or when not provided services will be discussed and the need to clearly document failure to attend scheduled sessions as stipulated. Clinical supervisor will monitor documentaion for compliance and program director will oversee this compliance issue. Completion Date 7/1/2014 |