Observations
Based on a review of client records, the facility failed to provide couseling services according to the individual treatment and rehabilitation plan.
Client #3 was admitted on August 29, 2023 and discharged on January 11, 2024. An individual treatment plan was documented on September 14, 2023 and it stated that individual sessions were to be conducted twice per week for the first month of treatment and then weekly thereafter. No individual treatment sessions were documented for the weeks of September 17 and 24, October 8, 15, 22 and 29, November 5 and December 17, 2023.
Client #4 was admitted on February 29, 2024 and is still active in treatment. An individual treatment plan was documented on February 29, 2024 and it stated that individual sessions were to be conducted twice per week for the first month of treatment and then weekly thereafter. Only one individual treatment session was documented for the weeks of March 7, 15, 21 and 29, 2024.
These findings were reviewed with faciltiy staff during the onsite investigation.
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Plan of Correction
Effective immediately, Clinical Manager will review all treatment plans prior to approval to ensure the accuracy of counseling services indicated on the individual treatment plan. Clinical Manager and Director will review completed sessions weekly to ensure sessions occur and are documented as outlined on the treatment plan. |