Observations
Based on a review of client records, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in four of eleven client records reviewed.
The findings include:
Eleven client records were reviewed on 11/17/15 and 11/18/15. The facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in records # 3, 6, 8, and 10.
Client # 3 was admitted into treatment on 5/20/15 and was still active at the time of the inspection. The client's individual treatment and rehabilitation plan, dated 5/27/15, stated that the client was to receive individual counseling sessions once a week and group counseling sessions twice a week. As of 9/2/15, the facility scheduled group counseling sessions for the client on the following dates: 9/2/15, 9/9/15, 9/16/15, 9/23/15, 9/30/15, 10/7/15, 10/14/15, and 10/21/15. Treatment plan updates completed for the client failed to document specific changes to the frequency of treatment services for the client.
Client # 6 was admitted into treatment on 3/6/15 and was discharged on 6/17/15. The client's individual treatment and rehabilitation plan, dated 3/10/15, stated that the client was to receive individual counseling sessions once a week and group counseling sessions twice a week. The facility scheduled group counseling sessions for the client on the following dates: 4/2/15, 4/7/15, 4/9/15, 4/14/15, 4/16/15, and 4/23/15. The client was last scheduled for a group counseling session on 4/23/15. Treatment plan updates completed for the client failed to document specific changes to the frequency of treatment services for the client.
Client # 8 was admitted into treatment on 3/26/15 and was discharged on 8/10/15. The client's individual treatment and rehabilitation plan, dated 4/10/15, stated that the client was to receive individual counseling sessions once a week and group counseling sessions twice a week. As of 5/28/15, the facility scheduled group counseling sessions for the client on the following dates: 6/3/15, 6/10/15, 6/15/15, 6/22/15, 7/13/15, and 7/20/15. Treatment plan updates completed for the client failed to document specific changes to the frequency of treatment services for the client.
Client # 10 was admitted into treatment on 1/22/15 and was discharged on 8/17/15. The client's individual treatment and rehabilitation plan, dated 2/6/15, stated that the client was to receive individual counseling sessions once a week and group counseling sessions twice a week. As of 3/31/15, the facility scheduled group counseling sessions for the client on the following dates: 3/31/15, 4/2/15, 4/7/15, 4/9/15, 4/14/14, 4/16/15, and 4/21/15. The client was last scheduled for a group counseling session on 4/21/15. Treatment plan updates completed for the client failed to document specific changes to the frequency of treatment services for the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director shall educate staff on DDAP regulations that do not differentiate between outpatient and intensive outpatient and the need to document in the record type and frequency. The facility director will retrain all staff so that the type and frequency is clearly documented on the comprehensive treatment plan. The facility director will also retrain staff to document on the treatment review and the comprehensive treatment plan type and frequency when there is a change in the level of care. The training will be documented in our facilities staff meeting minutes and the facility director will do open and closed chart audits to verify that staff are meeting this requirement. The education will be completed by January 2016 and the audits will begin in February 2016. |
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which included the specific information disclosed and the purpose of disclosure in one of eleven client records reviewed.
The findings include:
Eleven client records which required documentation of an informed and voluntary consent were reviewed on 11/17/15 and 11/18/15. The facility failed to obtain an informed and voluntary consent which documented the specific information disclosed and the purpose of disclosure in client record # 11 .
Client # 11 was admitted into treatment on 1/28/15 and was discharged on 9/8/15. The consent to release information for a substance abuse professional, signed and dated on 7/22/15, failed to document the specific information disclosed and the purpose of disclosure. Additionally, the client's record documented a letter mailed to the substance abuse professional, dated 9/9/15, disclosing the client's prognosis and discharge from treatment.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation for the facility, as the facility was cited for non-compliance of this standard during the previous licensing renewal inspection completed on 11/5/14.
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Plan of Correction
The facility director will discuss the finding with staff regarding the confidentiality regulation and remind staff to thoroughly review the release of information to ensure that appropriate check boxes are checked. The facility director will reeducate staff on the confidentiality regulations and will audit open and closed charts to verify that this oversight does not reoccur. This will be completed by January 2016 and audits will begin February 2016. |