Observations
Based on the review of the client records, the facility failed to document progress notes for group counseling sessions in three of three client records. Additionally, the facility failed to document individual and group counseling sessions on the record of service in one of three client records.
The findings included:
Three client records were reviewed on August 22, 2014. The facility did not document progress notes for group counseling sessions in client records #1, #2, and #3. The facility failed to document an individual counseling session on the record of service in client record #3.
Client #1 was admitted to treatment on 8/7/14. The client attended group counseling sessions on 8/19/14, 8/20/14, and 8/21/14. There were no progress notes completed for these group counseling sessions.
Client #2 was admitted to treatment on 8/7/14. The client attended group counseling sessions on 8/7/14, 8/19/14, 8/20/14, and 8/21/14. There were no progress notes completed for these group counseling sessions.
Client #3 was admitted to treatment on 6/30/14. There were no progress notes completed for the group counseling sessions that the client attended on 7/18/14, 7/25/14, 8/1/14, 8/8/14, and 8/15/14. Additionally, the individual counseling session on 7/7/14 and the group counseling sessions on 7/22/14, 8/5/14 and 8/12/14 that the client attended were not documented on the record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure timely documentation of progress notes for group counseling sessions and individual counseling sessions and record of service, all counselors will submit to the Clinical Supervisor, group notes on Mondays before 4:00 p.m. for previous week groups.
The Clinical Supervisor shall ensure compliance with this procedure. |