Observations
Based on a review of seven client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in four records reviewed.Client #1 was admitted on June 22, 2020 and was still active at the time of the inspection. The treatment plan, dated April 14, 2021, indicated 1 group session per week and one individual session per week. The client ' s record of service and progress notes indicated that the client had received no group sessions since May 27, 2021 and no individual session since May 26, 2021.Client #3 was admitted on October 26, 2020 and was still active at the time of the inspection. The treatment plan, dated December 18, 2020, indicated 1 group sessions per week and one individual session per week. The client's record of service and progress notes indicated that the client had received no group sessions from April 20, 2021 until June 14, 2021 and no individual session between May 13, 2021 and June 17, 2021.Client #5 was admitted on August 11, 2020 and was discharged on April 30, 2021. The treatment plan, dated February 5, 2021, indicated 1 group sessions per week and one individual session per week. The client's record of service and progress notes indicated that the client had received no group sessions since March 2, 2021 until discharge and no individual session since March 17, 2021 until discharge.Client #6 was admitted on October 21, 2020 and was discharged April 30, 2021. The treatment plan, dated December 31, 2020, indicated 1 group sessions per week and one individual session per week. The client's record of service and progress notes indicated that the client had received no individual sessions from December 23, 2020 until February 9, 2021 and again from February 9, 2021 until March 3, 2021 and no group session from December 8, 2020 until February 10, 2021 and no group session from February 25, 2021 until discharge. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
All staff have been trained regarding the requirement to provide counseling services according to the individual treatment and rehabilitation plan. This training occurred on 7/9/21. The Program Director will monitor to ensure compliance through monthly audits of clinical records, and follow up on any inconsistencies in clinical supervision sessions. The Quality Assurance department will conduct quarterly program review, and the Compliance department will review the plan of correction at least annually to ensure implementation. |
Observations
Based on a review of client records, the facility failed to ensure that all discharged clients received a discharge summary in two of the three applicable records reviewed. Client #5 was admitted on August 11, 2020 and discharged April 30, 2021.Client #6 was admitted on October 21, 2020 and discharged on April 30, 2021. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
All staff have been trained regarding the requirement to complete a discharge summary for all discharged clients. This training occurred on 7/9/21. The Program Director will monitor to ensure compliance through monthly audits of clinical records, and follow up on any inconsistencies in clinical supervision sessions. The Quality Assurance department will conduct quarterly program review, and the Compliance department will review the plan of correction at least annually to ensure implementation. |