Observations
Based on the review of patient records, the facility failed to ensure that each patient received an average of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of which shall be individual psychotherapy, in two of six patient records. The findings include: Nineteen patient records were reviewed on March 17-18, 2014. Six patient records required documentation of an average of 2.5 hours of psychotherapy per month. The facility failed to document the required number of hours of psychotherapy in patient records # 5 and 7.Patient # 5 was admitted on November 15, 2013 and required an average of 2.5 hours of psychotherapy per month. The patient received 2.50 hours in December, 2013; 2.50 hours in January, 2014 and 0 documented psychotherapy hours for February, 2014 for an average of 1.66 hours.Patient # 7 was admitted on January 7, 2013 and required an average of 2.5 hours of psychotherapy per month. The patient received 1.25 hours in December, 2013; 1.25 hours in January, 2014 and 2.50 documented psychotherapy hours for February, 2014 for an average of 1.66 hours.The Facility Director was interviewed on March 20, 2014 and confirmed the findings.
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Plan of Correction
The facility failed to ensure that each patient received an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment, 1 hour of which shall be individual psychotherapy.
All patients within the first 2 years in treatment will receive an average of 2.5 hours of psychotherapy per month. All patients will receive at least 1 hour of individual psychotherapy each month. The Facility Director and Clinical Supervisor will be responsible for assuring that patients are attending psychotherapy regularly. Facility Director and Clinical Supervisor will conduct ongoing reviews to assure that the hours are met.
All staff will be educated on the regulations regarding psychotherapy attendance on April 1, 2014. |