Observations
Based on a review of client records on May 10, 2016, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in records # 2, 4, 7 and 8.
Client #2's treatment plan dated January 19, 2016 and update of April 1, 2016, stated that the client was to receive individual counseling sessions once per week. Client #2 received individual counseling sessions on 1/20/16, 2/3/16, 2/18/16, 2/24/16, none for the month of March, 4/1/16 and 4/28/16. Client is currently active.
Client #4's treatment plan dated February 3, 2016 and update of April 3, 2016, stated that the client was to receive individual counseling sessions once per week. Client #4 received individual counseling sessions on 3/2/16, 3/16/16, 3/30/16, 4/13/16, 4/27/16, and none for the month of May. Client is currently active.
Client #7's treatment plan updates of December 16, 2015 and January 25, 2016 stated that the client was to receive individual counseling sessions once per week. Client #7 received individual counseling sessions on 12/16/15, 1/4/16 and 1/25/16 prior to discharge of 2/9/2016.
Client #8's treatment plan updates of September 13, 2015 and November 13, 2015 restated that the client was to receive individual counseling sessions once per week. Client #8 received individual counseling session on 8/31/15, none for the month of September, 10/18/15, none for the month of November or December, prior to discharge of 1/4/16.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training will be held on June 17, 2016 to address clinical staff on treatment management procedures specific to assuring that counseling services are provided according to the individual and treatment plan updates. All staff will be directed to schedule clients according to their treatment recommendation and document weekly on the client record of service. Any deviation from the set course of treatment will also be documented on the record of service. The Clinical Supervisor as well as the Division Director will review treatment plans recommendations and compare it to the record of service for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions as well as weekly during clinical meeting. |