Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in three of ten records reviewed.
The findings included:
Ten client records requiring the documentation of the provision of services in accordance with those specified in the treatment plan were reviewed on December 17, 2014. The facility failed to provide counseling services as stated in the treatment and rehabilitation plan in client record #'s 3, 5, and 7.
Client #3 was admitted to treatment on May 28, 2014 and was still an active client at time of the inspection. An individual treatment and rehabilitation plan was developed with the client on 5/28/2014 and the plan stated that the client would be provided individual sessions 1 time per week and group sessions 1 time per week. During the month of June 2014, the client did not have any individual sessions. During the month of July 2014, the client had two individual sessions (7/28 and 7/31). During the month of August 2014, the client did not have any individual sessions. During the month of September 2014, the client had three individual sessions (9/11, 9/18, and 9/25). During the months of October 2014, November 2014, and December 2014, the client did not have any individual sessions.
Client #5 was admitted to treatment on June 17, 2014 and was discharged on October 23, 2014. An individual treatment and rehabilitation plan was developed with the client on 06/17/2014 and the plan stated that the client would be provided 2 individual sessions per month and 1 group session per week. During the second half of June 2014, the client did not have any group sessions. During the month of July 2014, the client only had one individual session (7/30). During the month of August 2014, the client did not have any individual sessions. During the month of September 2014, the client only had one individual session (9/29). During the month of October 2014, the client only had one individual session (10/20).
Client #7 was admitted to treatment on June 30, 2013 and was discharged on November 17, 2014. An individual treatment and rehabilitation plan was developed with the client on 6/30/2014 and the plan stated that the client would be provided individual sessions 1 time per week and group sessions 3 times per week. During the month of July 2014, the client did not have any individual sessions. During the month of August 2014, the client only had one individual session (8/19). During the month of September 2014, the client only had one individual session (9/02). During the month of October 2014, the client only had one individual session (10/07). During the month of November 2014, the client did not have any individual sessions
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following the Inspection, Executive Director and Clinical Supervisor met to discuss the finding regarding the failure of the project to provide counseling services according to the individual treatment and rehabilitation plan. Based on the discussion with the Licensing Specialist at the close of the inspection process and Executive Director, Clinical Supervisor took the following actions: The treatment and rehabilitation plan template, treatment plan update template and counseling agreement form were all updated and given a uniform, concise space to enter the frequency and duration of treatment contacts, separating group and individual modalities. This will provide continuity across all treatment and rehabilitation plan documents and prompt counseling staff to document treatment attendance recommendations and expectations uniformly and clearly. Additionally, reflective of these changes, Clinical Supervisor discussed with counseling staff the necessity to individualize treatment and rehabilitation plans, specifically when recommending individual treatment sessions, to use distinct language such as "weekly" or "bi-weekly" rather than a range such as "weekly and/or bi-weekly." Clinical support staff was directed to log all scheduled individual and group sessions, (not just those completed) in each client file to reflect these sessions were indeed scheduled and what the outcome of each scheduled appointment was. Clinical support staff was also directed to access the interoffice scheduling system counselors use to obtain daily appointments scheduled as well as utilize group rosters and individual encounter sheets for logging purposes. Logging in this more detailed manner increases accuracy and whether the treatment and rehabilitation plan is being executed properly. Both counseling staff and support staff verbalized an understanding of these expectations and were provided with an email to follow up/document the discussion. |