Observations
Based on a review of three partial hospitalization client records during the annual inspection conducted on May 6, 2016, the facility failed to provide individual counseling, at least twice weekly in client records # 1, 2 and 3.Client # 1 was admitted into treatment on January 22, 2016. The facility only provided one individual counseling session for the following weeks: 2/22/16, 3/7/16, 3/21/16, 4/4/16 and 4/11/16. The facility did not provide any individual counseling sessions for the following weeks: 3/14/16 and 3/28/16.Client # 2 was admitted into treatment on March 22, 2016. The facility only provided one individual counseling session for the following weeks: 4/11/16, 4/18/16 and 4/25/16. Client # 3 was admitted into treatment on November 16, 2015 and discharged on December 9, 2015. The facility only provided one individual counseling session for the week of 11/30/15. The facility did not provide any individual counseling sessions for the following weeks: 11/16/15 and 11/23/15.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the deficiency with the Clinical Director and Office Manager on 5/24/16. They will review the regulation requirements with all staff at the June staff meeting. The Clinical Director has reviewed the standard with the Partial Hospital Therapist and they will immediately schedule individual sessions with each PH Patient 2 xs/week. The Clinical Director will review compliance during weekly chart audits and treatment plan updates with the PH Therapist. The Clinical Director will inform the Facility Director monthly of their findings. |