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 three of seven client records. Client #1 was admitted to the outpatient level of care on August 3, 2022 and was active at the time of review. Client #1 ' s record contained a treatment and rehabilitation plan dated January 8, 2023 that indicated a frequency of service of one group session every other week. No group sessions were documented in the record of service or in progress notes between the dates of January 8, 2023 and March 8, 2023. Client #3 was admitted to the outpatient level of care on March 2, 2022 and was active at the time of review. Client #3 ' s record contained a treatment and rehabilitation plan dated February 1, 2023 that indicated a frequency of service of four individual sessions per month. An individual session was documented on February 6, 2023 and February 22, 2023. No other individual sessions were documented for the month of February, 2023. Client #5 was admitted to the outpatient level of care on April 8, 2022 and was discharged April 6, 2023. Client #5 ' s record contained a treatment and rehabilitation plan dated October 9, 2022 that indicated a frequency of service of six hours of group per week. During the week of October 31, 2022 only three hours of group were documented. During the week of November 7, 2022 no group hours were documented. During the week of November 14, 2022 only 1.5 hours of group were documented. During the week of November 21, 2022 no hours of group were documented. During the week of November 28, 2022 only 1.5 hours of group were documented. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Observation #1885 which took place 5/30/23 in the Washington office was discussed with all AAR staff in staff meeting on June 13, 2023 to ensure that all counseling services are provided in accordance with DDAP regs.
AAR treatment planning will be sure that counseling services match/follow the individual treatment and rehabilitation plan.
AAR Treatment Supervisor will review patient charts weekly for compliance accuracy.
AAR Clinical Supervisor will review treatment plan updates with Therapists to ensure accuracy for adherence to services rendered and documentation. |