Observations
Based on a review of client charts during a complaint investigation conducted on February 15, 2022, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.Client #3 Admitted 11/1/2021 Discharged 12/15/2021: The comprehensive treatment plans dated 11/10/2021 and 12/3/2021 indicated that the client was to receive individual counseling weekly. However, the client chart contains only one individual session progress note. There were no other progress notes for weekly individual sessions during this time period. This was discussed with the facility staff during the complaint investigation.
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Plan of Correction
Clinical Director will complete weekly chart audits on all residential clients to ensure that individual sessions are being completed on a weekly basis and all documentation is completed and within the chart. All progress notes for individual sessions and group sessions will be completed as per the treatment plan and will be signed by the counselor within no more than 48 hours of the session being completed. This standard will be reviewed during individual supervision sessions and during group supervisions. |