Observations
The facility failed to provide the client individual counseling at least twice weekly, in three of three client records reviewed on January 24, 2018.
Three partial hospitalization client records were reviewed.
Client # 1 did not document twice weekly individual counseling sessions for nine of ten weeks.
Client # 2 did not document twice weekly individual counseling sessions for five of five weeks.
Client # 3 did not document twice weekly individual counseling sessions for four of four weeks.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Supervisor will schedule a mandatory staff meeting which will focus on reiterating the requisite that all Partial Hospitalization Program (PHP) clients are to be scheduled for 2 individual sessions per week at a minimum. Direct Service Staff will be advised to allot additional blocks in their schedules for PHP clients. The Supervisor will devise a spreadsheet that will be distributed to direct service staff in an effort to enhance tracking of individual sessions for clients in the Partial Hospitalization Program. Additionally the Program Supervisor will monitor this effort via random PHP chart audits. Staff will be reminded that receipt of reasons for clients' treatment inadherence must be documented in their Electronic Health Record (EHR). The correction was implemented and completed before February 1, 2018. |