Observations
Based on a review of patient records, the facility failed to assure counseling services were provided according to the individual treatment and rehabilitation plan in one of three patient records reviewed.
Patient # 1 was admitted on February 6, 2017, and was discharged on May 21, 2026. A treatment plan dated April 10, 2026, indicates the patient is to have weekly group counseling sessions. There was no documentation for group counseling sessions for the weeks of April 20, 2026, April 27, 2-26, May 4, 2026, or May 11, 2026.
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Plan of Correction
On July 15, 2025, clinicians were reminded that counseling services must be delivered as documented in each patient's treatment plan. The Facility Director also reinforced the need to document any scheduled counseling service that is not completed because of a patient cancellation or no-show.
The Clinical Supervisor will monitor compliance by reviewing the monthly counseling report and comparing documented counseling hours with randomly selected treatment plans to verify that services are provided according to each plan's schedule.
If a record review shows that a client is not following treatment plan recommendations, the treatment team will address the issue during team review.
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