Observations
Based on the review of client records, the facility failed to document the assurance that counseling services are provided according to the individual treatment and rehabilitation plan in five of six client records.
Findings:
Nine client records were reviewed on May 7, 2009. Eight were required to have documentation that counseling services are provided according to the individual treatment and rehabilitation plan. Documentation indicated that the client had not received counseling services according to the individual treatment and rehabilitation plan in client records # 1, 2, 4, 5 and 6.
In client record #1, the client was to receive 1 group counseling session a week and 1 individual counseling session every other week. The client did not receive 1 group counseling session a week for the week of December 22, 2008 and the weeks of March 9 and April 6, 2009.
The client did not receive 1 individual counseling session every other week for the weeks of November 11, November 26, 2008 and the weeks of March 9 and April 6, 2009.
In client record # 2, the client was to receive 2 group and 1 individual counseling sessions per week. The client did not receive 2 group counseling sessions for the weeks of March 16, March 23, April 6 and April 20, 2009.
In client record # 4, the client was to receive 1 group and 1 individual counseling session a week. The client did not receive 1 group counseling session for the weeks of April 13 and April 20, 2009.
The client did not receive 1 individual counseling session for the week of April 20, 2009.
In client record # 5, the client was to receive 3 group counseling sessions and 1 individual counseling session a week. Client did not receive 3 group sessions for the weeks of November 10, November 24, December 8, December 15, December 22, December 29, 2008; and the weeks of January 5, January 12, January 19, January 26, February 2, February 9, February 16, February 23, March 2, March 9, March 16, March 23, April 6, April 13, April 20 and April 27, 2009.
The client did not receive weekly individual counseling sessions for the weeks of November 13, November 17, December 12, December 22, December 29, 2008; and the weeks of January 12, January 16, February 9, February 23, March 2, March 16, March 23, April 6 and April 13, 2009.
In client record #6, the client was to receive 1 group counseling session and 1 individual counseling session per week. The client did not receive 1 group counseling session for the week of December 29, 2008 and the weeks of January 12, March 23, March 30 and April 6, 2009.
The client did not receive 1 individual counseling session per week for the weeks of January 12, March 9, March 16, March 30 and April 6, 2009.
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Plan of Correction
Clinical Staffing was held on Friday, May 15, 2009 @ 8:00 AM. Based on the results of our licensing review the following policy and procedures will be followed immediately:
- At any time, any change in the type and/or frequency of counseling services as reflected in the client's treatment plan, must be documented on a Treatment Plan Update, detailing the rationale and justification of such change. The Treatment Supervisor will monitor this requirement through random periodic chart audits and case review to assure compliance.
- Counseling sessions will be provided according to the client's individualized treatment and rehabilitative plan. All treatment sessions, individual and group, will be logged in the client service record. If a client misses an appointment or cancels an appointment which brings the number of identified sessions below what is specified in the Treatment and Rehabilitative Plan, there will be clear documentation as to the reason (s). Treatment supervisor will randomly monitor client charts for compliance.
- The Agency Treatment Manual will be updated to directly address this specific issue and a follow-up memo to counselors will be sent delineating the above procedure.
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