Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis, including individual counseling, at least twice weekly in four records reviewed in the partial hospitalization activity.
The findings include:
Eight client records were reviewed on December 8, 2011. Four of the eight client records were from the partial hospitalization activity. Four of four client records were required to include documentation of individual counseling at least twice weekly. Client records # 1, 2, 7 and 8 did not include documentation of individual counseling at least twice weekly.
Client record # 1 - The client was admitted to the partial hospitalization activity on 7-11-11 and was transferred to outpatient on 10-17-11. The client record was missing documentation of two individual treatment sessions per week while in the partial hospitalization activity.
Client record # 2 - The client was admitted to the partial hospitalization activity on 4-22-11 and was transferred to outpatient on 7-8-11, and was discharged on 8-26-11. The client record was missing documentation of two individual treatment sessions per week while in the partial hospitalization activity.
Client record # 7 - The client was admitted to the partial hospitalization activity on 2-8-11 and was discharged on 3-25-11. The client record was missing documentation of two individual treatment sessions per week.
Client record # 8 - The client was admitted to the partial hospitalization activity on 2-23-11 and was discharged on 8-9-11. The client record was missing documentation of two individual sessions per week while in the partial hospitalization activity.
The director confirmed on December 8, 2011 the records for the partial hospitalization activity did not include documentation of individual counseling at least twice weekly.
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Plan of Correction
The Outpatient Program Manager will review the clincical record on a regular basis to make certain that all levels of care are receiving the mandated number of individual sessions. The Program Manager will provide oversight and supervision to clinical staff regarding the mandated number of individual sessions for each level of care. Target date for POWER to be in full compliance is 01/27/2012. |