Observations
Based on a review of eight patient records during the annual inspection conducted on May 9, 2016, the facility failed to provide each patient with an average of 2.5 hours of psychotherapy per month in patient records # 6 and 10.
Patient # 6 was admitted into treatment on January 26, 2014 and discharged on October 4, 2015. The facility only provided the following monthly therapy hours: July 2015 - 1.5 hours of group therapy, August 2015 - 1.5 hours of group therapy and September 2015 - 0 hours of psychotherapy.
Patient # 10 was admitted into treatment on August 31, 2014. The facility only provided the following monthly therapy hours: February 2016 - 1.5 hours of individual therapy, March 2016 - 1.75 hours of individual therapy and April 2016 - 2 hours of individual therapy.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation information and regulation with the Clinical Director and Office Manager on 5/24/16. The information will be reviewed with all staff at the June staff meeting. Documentation of at least 2.5 hours of clinical services being scheduled for patients up to 2 years will be placed in the chart and on treatment plans. The clinical Director will include review of this standard compliance in their weekly chart audits and during treatment plan updates. She will report findings to the facility director monthly. |