Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in eight of ten records reviewed.
The findings included:
Ten client records requiring the documentation of the provision of services in accordance with those specified in the treatment plan were reviewed on September 10, 2015. The facility failed to provide counseling services as stated in the treatment and rehabilitation plan in client records, #1, 2, 3, 4, 5, 6, 8, and 9.
Client #1 was admitted to treatment on March 31, 2015 and was still an active client at time of the inspection. An individual treatment and rehabilitation plan was developed with the client on April 6, 2015 and the plan stated that the client would be provided individual sessions 2 time per week. During the month of June 2015, the client did not have any individual sessions until June 29, 2015. During the month of August, the client was seen on August 10th, 26th and cancelled on the 31st.
Client #2 was admitted on February 10, 2015 and was still an active client at the time of the inspection. An individual treatment and rehabilitation plan was developed with the client on February 18, 2015 and the plan stated that the client would be provided individual sessions 1 time per week. During the month of February 2015, the client was seen on February 18th, cancelled February 25th, and not seen again until March 18th. In July client was seen July 7th, cancelled July 14th, was seen July 28th and not again until September 1, 2015.
Client #3 was admitted on January 22, 2015 and was still an active client at the time of the inspection. An individual treatment and rehabilitation plan was developed with the client on February 4, 2015 and the plan stated that the client would be provided individual sessions biweekly. In March 2015 the client was seen on March 26 and not again until April 21st. The next individual session was June 9th, 2015.
Client #4 was admitted on December 2, 2014 and was still an active client at the time of the inspection. An individual treatment and rehabilitation plan was developed with the client on December 16, 2014 and stated that the client would be provided individual sessions 1 time per week. Client was seen on June 18th, cancelled on 6-25th and was rescheduled for June 29th. In July client cancelled July 7th, was seen July 21st, staff cancelled July 27th and client cancelled August 11th. Client was not seen again for a session until September 1, 2015.
Client #5 was admitted on January 23, 2015 and was still an active client at the time of the inspection. An individual treatment and rehabilitation plan was developed with the client on January 27, 2015 and the plan stated that the client would be provided individual sessions 2 times weekly. Client was seen on March 27th, was a no show on April 1st, was seen again April 20th, April 24th, April 29th, cancelled May 4th, was seen May 8th and then again June 15th and June 29th. Client was not see in July and in August only on the 31st.
Client #6 was admitted on November 7, 2014 and was discharged on June 20, 2015. An individual treatment and rehabilitation plan was developed with the client on November 14, 2014 and the plan stated that the client would be provided individual sessions 1 time per week. Client was seen February 11th, cancelled February 23rd, was seen March 3rd, March 16th, and April 22, 2015.
Client #8 was admitted on February 18, 2015 and discharged July 17, 2015. An individual treatment and rehabilitation plan was developed with the client on March 30, 2015 and the plan stated that the client would be provided individual sessions biweekly. Client was seen March 30th, March 4th and cancelled July 17, 2015.
Client #9 was admitted on September 29, 2014 and discharged February 5, 2015. An individual treatment and rehabilitation plan was developed with the client on October 27, 2015 and the plan stated that the client would be provided individual sessions 1 time weekly. Client was seen November 3rd, cancelled November 11th and December 2nd, was seen December 9th and December 30th, and cancelled January 15, 2015.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Northern Tier Counseling, Inc.
Plan of Correction
09/25/2015
709.92(c) LICENSURE
Observation #1885
Treatment and rehabilitation services:
709.92. Treatment and rehabilitation services. (c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
As part of our Plan of Correction; clinical staff members within the Drug and Alcohol Program will be conducting chart audits/peer review of 10% of active charts on a monthly basis during regularly scheduled staff meetings, to ensure compliance to the original prescription of hours noted by the treating therapist based on their assessment at intake. This will then be compared to the Treatment & Rehabilitation Plans in the chart as compared to actual attendance. If Treatment Services are not being provided as prescribed as noted in the Intake/Assessment or most current Treatment/Rehabilitation Plan- the client will be scheduled (if not already) and the next scheduled session will be spent reviewing attendance, conducting a Treatment Plan/Rehabilitation Plan review, or mailing correspondence to the client to attempt to re-engage them into treatment.
The Program Supervisor will also conduct random audits on a quarterly basis to review the same.
Education and training have been completed with all Program Staff on 9/25/15, relating to this issue- to include thorough documentation of case management/non clinical conversations with clients related to cancellation/rescheduling of appointments.
Education and training have been completed with all Program Staff on 9/25/15, related to letter correspondence to re-engage clients back into treatment or as a last resort; close their case with the agency.
|