Observations
Based on a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in five out of seven charts reviewed.
Client #1 was admitted on May 27, 2022 and was discharged on September 19, 2022. The comprehensive treatment plan, dated June 13, 2022, indicated biweekly individual sessions. The client did not receive any individual sessions between July 2, 2022 and July 20, 2022.
Client #4 was admitted on September 22, 2022 and was discharged on February 22, 2023. Two treatment plans, dated October 26, 2022 and December 21, 2022, indicated biweekly individual sessions. The client did not receive any individual sessions between October 27 - November 14, 2022, November 30 - December 19, 2022 and December 21, 2022 - January 9, 2023.
Client #5 was admitted on June 30, 2022 and was still active at the time of the inspection. A treatment plan dated September 2, 2022 indicated weekly individual sessions. The client did not receive any individual sessions between September 21 - October 6, 2022.
Client #6 was admitted on October 27, 2022 and was still active at the time of the inspection. A comprehensive treatment plan dated November 11, 2022 indicated biweekly individual sessions. The did not receive any individual sessions between November 12 - December 1, 2022.
Client #7 was admitted on August 18, 2022 and was still active at the time of the inspection. A comprehensive treatment plan dated September 16, 2022 indicated biweekly sessions. The client did not receive any individual sessions between September 30 - October 19, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A clinical staff meeting was held on 3/17/23 with all three (3) facility locations to review results of facility inspections. The Project Director, Facility Director and clinical supervisor reviewed 709.92. Treatment and rehabilitation services. (c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Effective 3/24/23 all staff will reference individual treatment and rehabilitation plan to ensure patients are receiving counseling services according to their treatment plan. Staff members will accurately document within patients' chart if recommended frequency cannot be met and the reason why. Staff members will revise all treatment plans accordingly based upon patients' individual needs.
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