Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent that includes all of the required content required by regulation in one of ten client records reviewed.
The findings include:
Ten client records requiring informed and voluntary consent to release information forms were reviewed on 2/10/2015. The facility failed to document the specific information to be disclosed and the purpose of disclosure on an informed and voluntary consent to release information form in client record # 8.
Client # 8 was admitted to treatment on 5/30/2014. Client # 8's informed and voluntary consent to release information to Limerick Counseling dated 6/5/2014 did not include the specific information to be disclosed and the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The requirements for completion of a valid consent will be reviewed individually with each therapist, and also reviewed in a staff meeting on 3/9/15.
Charts will be reviewed for compliance on a quarterly basis by site director chart audits, and review of consents, particularly the notation of what information is to be released, will be reviewed via audit. Ongoing staff trainings will also review the requirements for valid consents. |
Observations
Based on the review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in six of ten client records reviewed.
The findings include:
Ten client records were reviewed for counseling services on 2/10/2015. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records # 1, 3, 7, 8, 9 and 10.
Client record # 1 contained a treatment plan dated 11/6/2014 that identified the counseling services to be provided as group therapy sessions 4 times per week. The only group therapy sessions scheduled between the weeks of 11/30/2014 - 1/3/2015 for the client were on 12/3/2014, 12/4/2014, 12/8/2014, 12/16/2014, 12/17/2014, 12/18/2014, 12/22/2014, 12/23/2014, 12/29/2014 and 12/20/2014.
Client record # 3 contained a treatment plan dated 12/26/2014 that identified the counseling services to be provided as group therapy sessions 4 times per week. The only group therapy sessions scheduled between the weeks of 12/28/2014 - 1/31/2015 for the client were on 12/30/2014, 1/2/2015, 1/6/2015, 1/9/2015, 1/12/2015, 1/16/2015, 1/19/2015, 1/23/2015 and 1/26/2015.
Client record # 7 contained a treatment plan dated 10/1/2014 that identified the counseling services to be provided as group therapy sessions 3 times per week. The only group therapy sessions scheduled between the weeks of 11/2/2014 - 12/20/2014 for the client were on 11/3/2014, 11/10/2014, 11/12/2014, 11/19/2014, 12/1/2014, 12/3/2014, 12/17/2014 and 12/18/2014.
Client record # 8 contained a treatment plan dated 7/22/2014 that identified the counseling services to be provided as group therapy sessions 4 times per week. The only group therapy sessions scheduled between the weeks of 7/27/2014 - 9/13/2014 for the client were on 8/1/2014, 8/12/2014, 8/19/2014, 8/22/2014, 9/2/2014 and 9/9/2014.
Client record # 9 contained a treatment plan dated 12/5/2014 that identified the counseling services to be provided as group therapy sessions 4 times per week. The only group therapy sessions scheduled between the weeks of 12/7/2014 - 1/24/2015 for the client were on 12/9/2014, 12/16/2014, 12/23/2014, 12/30/2014, 1/6/2015 and 1/23/2015.
Client record # 10 contained a treatment plan dated 10/6/2014 that identified the counseling services to be provided as group therapy sessions 4 times per week. The only group therapy sessions scheduled between the weeks of 10/12/2014 - 11/1/2014 for the client were on 10/17/2014, 10/20/2014 and 10/27/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be oriented individually and in a group supervision session on 3-9-15 regarding the need to document compliance with attendance requirements of the treatment established for each client.
When a client does not attend the therapy sessions, appropriate documentation of the reason the client was not in attendance, outreach to client as needed, and appropriate follow-up will be documented in the client chart.
Clinical supervisor will review compliance via individual case reviews on a monthly basis and chart audits on a regular basis, including quarterly chart audits. |