Observations
The facility failed to assure that patients received the required counseling services according to that patient's comprehensive treatment plan in one of one client records reviewed.
Patient #1 was admitted on April 11, 2017 and was administraively discharged on June 27, 2019. The patient's December 19, 2018 treatment plan update indicated that the patient was to receive one individual therapy session per week. The patient's record of service and progress notes indicated that the client had individual sessions scheduled for April 1, 2, 4, 8, 9, 11, 15, 16, 18, 22, 23, 25, 29, 30; May 2, 7, 20, 21, 23, 29, 30; and June 3, 6. However, according to the notes on the record of services, each one of those indiviudal sessions were cancelled by the facility's therapist.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/23/19, Division Director and Clinical Supervisor met with the therapist to whom Patient #1 was assigned to and reviewed these findings. The clinician indicated that they had not cancelled any of these individual sessions due to absence. These session did not occur because the patient did not attend. The therapist in question had been using the incorrect coding on their daily activity sheer, indicating therapist cancellation for all sessions not attended. Director and Clinical Supervisor provided training on 9/23/19 to ensure that therapist was using the proper code and understood the difference between a no-show and a therapist cancellation. At this time, therapist verbalized understanding. Clinical Supervisor will monitor this therapist's daily activity sheet moving forward to ensure this coding error does not persist. |