Observations
Based on a review of supervision notes, the facility failed to document close supervision in two counselor assistant personnel records.
Findings:
Two personnel records and supervision documentation were reviewed on January 14, 2009. Close supervision of one hour direct observation and formal documentation of one hour of supervision per week was required for two personnel records, #6 and 8. The facility documented supervision notes for 12/4/08 and 12/18/08 for #6 and 8. #6 was hired on 12/1/08 and #8 was hired on 11/24/08. Supervision notes did not document direct observation from date of hire. Progress notes were reviewed for two client records assigned to #6 and 8 which did not document direct observation. A conversation with the clinical supervisor on 1/14/09 confirmed that direct observation had not been documented.
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Plan of Correction
Clinical supervisors will be trained to fully implement the close supervision process as required by the Deptartment for all Counselor Assistants.
The Division Director will ensure through periodic monitoring that the close supervision model is fully mplemented as defined by the regulation. |
Observations
Based on a review of fourteen client records, the facility failed to document that counseling services are provided according to the individual treatment plan in eight client records.
Findings:
Fourteen client records were reviewed on January 15 and 16, 2009. Counseling services provided according to the individual treatment plan were required in 10 client records.
The facility failed to provide counseling services once per week as prescribed in the individual treatment plan in seven of ten client records. Individual counseling sessions were prescribed once a week in the individual treatment plans.
Based on a review of the progress notes and the record of services in client records # 2, 3, 4, 6, 7, 8 and 9 the clients did not receive one individual session per week as prescribed in the individual treatment plan.
Client record #2 had individual sessions documented for 9/10, 9/17, 9/24, 10/9, 10/22, 11/5, 11/21, 12/3 and 12/7/08.
Client record #3 had individual sessions documented for 10/6, 12/8, 12/12, 12/19, and 12/23/08. Client #3 was admitted on 9/22/08.
Client record #4 had individual sessions documented for 8/13, 8/27, 9/2, 9/19, 11/12, 11/19, 11/25, 12/12 and 12/15/08.
Client record #6 had individual sessions documented for 10/6, 10/20, 10/27, 11/3, 11/17, 12/1 and 12/29/08.
Client record #7 had individual sessions documented once a week in October, 2008, then on 11/24, 12/1, 12/15 and 12/29/08.
Client record #8 had individual sessions documented for 7/1, 8/5, 8/12, 8/26, 9/3, 9/9, 9/16, 9/23, 9/30, 10/7, 10/14, 10/21, 11/4, 11/11, and 11/18/08. Client #8 was admitted on 6/16/08.
Client record #9 had individual sessions documented for 8/11, 9/19, 10/13 and 11/17/08.
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Plan of Correction
Allstaff will be trained to continue to adhere to the prescription outlined in the Master Treatment Plan by 1/29
If a consumer misses a scheduled individiual session, the counselor will be trained to document the "no show" session by making an entry on the record of service.
Quality Assurance will monitor this process weekly through various audits and supervision meetings with staff |