Observations
Based on a review of 6 patient records and interviews with staff on September 4, 2008, in which all patient records were reviewed for consistency with the records of services, the facility failed to accurately document the specific nature of the counselor's contact with the patient in 2 of 6 patient records where required.
Findings:
A review of the records of services for patients # 4 & 5 revealed that patients attended support group meetings that were documented as psychotherapy hours. Further, interviews with administrative staff, the team leader and lead counselor confirmed that support group meetings were documented as clinical hours in the records of services.
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Plan of Correction
Plan of Correction:
Clients will attend support groups with the counselor present. The primary counselor will document Support groups meetings as "Support/Process group". Clients will attend support groups and will process group interactions following the meeting with their counselor. The facility director will oversee the programming and monitor random charts to ensure documentation on the process of the group.
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