Observations
Based on the review of client records, the facility failed to ensure that a complete record was documented in two of five client records reviewed.The findings include:Five client records were reviewed for documentation of a complete client record during the renewal inspection on March 3-4, 2016. The facility failed to document a complete record in client records # 2 and 5. Client # 2 was admitted into the facility for treatment on 7/6/15 and was still active at the time of the inspection. The record of service for the client indicated that the client attended an individual counseling session on 2/24/16. A progress note for this individual counseling session was not documented in the client's record. Additionally, a progress note documented in the client's record indicated that the client attended an individual counseling session on 2/25/16. This individual counseling session was not documented on the record of service. Client # 5 was admitted into treatment on 8/17/15 and was still active at the time of the inspection. A progress note documented in the client's record indicated that the client attended a group counseling session on 1/26/16. This group counseling session was not documented on the client's record of service. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Lead Counselor will review charts of all patients who received a clinical service that day. She will check that the progress note date and case summary log dates are correct and match the date of service. She will check that all group attendance from that day is logged on the patients' case summary sheet in their chart. Furthermore, Chart audits will be completed by peers, supervisor, and director and the correct documentation of services provided will be confirmed. |