Observations
Based on a review of patient records, the facility failed to provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment in one of two patient records.The findings include:Thirty one patient records were reviewed on April 8-9, 2013. Two of the patients reviewed were in their third or fourth year of treatment and required at least 1 hour of psychotherapy per month. Patient #7 was not provided with at least 1 hour of psychotherapy per month, as required.Patient #7 was admitted to treatment on September 16, 2009 and is required to have at least 1 hour of psychotherapy per month. Patient #7 did not have any psychotherapy in January 2013 and March 2013. Patient #7 had 1.25 hours of psychotherapy in February 2013. A case consultation dated January 18, 2013 stated that patient #7 was to have counseling for 1 hour every other month but the regulations require monthy counseling.An interview with the clinical supervisor took place on April 9, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
The facility failed to provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment in one of two patient records.
In this case, the identified patient was not eligible through regulation for a reduced monthly therapy committment.
In order to prevent this from occurring in the future, all potential candidates for reduced counseling must have their clinical record submitted to the Pinnacle Clinical Director for review and approval.
The Facility Director is responsible for ongoing monitoring and maintenance of this standard.
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