Observations
Based on a review of client records, the facility failed to provide individual counseling to the client on a regular and scheduled basis in one of three client records.
The facility policy in regards to individual couseling states, " All residents will be assigned to a primary therapist upon admit and will meet with that individual no less than once every seven days. "
Client #3 was admitted on February 29, 2024 and disharged on August 9, 2024. Client #3 had treatment plans documented on March 14, April 11, May 13, June 12 and July 11, 2024, all of which state that the client will receive individual counseling on a biweekly basis. It was confirmed with facility staff that this type and frequency was incorrect and clients are to be seen individually at least once per week. Client #3 completed individual sessions weekly for the months of March and July 2024; however, the client only had one individual session for the month on April 11, two individual sessions on May 2, 16 and three individual sessions on June 3, 18 and 25, 2024.
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Plan of Correction
Director and Administrative Assistant will update all policies and procedures to reflect services being provided. Services provided are : Clients will meet with their assigned therapist, or another clinical staff member if therapist is unavailable, at least 1 time every 7 days for a total of no less than 60 minutes.
HLC Clinical Supervisor will review therapist's electronic client charts once every other week for completion of individual session notes. This review will include checking that the individual session notes are completed in entirety, on time, and in compliance with all documentation standards.
If a note is found to be noncompliant or incomplete then the therapist will be made to complete the note immediately with clinical supervisor supervision. Any therapist with an instance of 2 or more notes to be found late, incomplete, or in noncompliance within a 1 month period will be subject to disciplinary action. |