Observations
The facility failed to provide a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance.
An onsite complaint investigation was conducted on February 26 and March 2, 2020. The licensing specialist reviewed six client records and was attempting to review the frequency of group therapy sessions for each of the clients reviewed. All group activities - therapy, educational and recreational are entered with the same heading. It was difficult to distinguish between therapy groups and non-therapy groups. The format of the progress notes was not standardized. Some therapist utilized the DAP format, others did not. Some support staff utilized the DAP format for educational groups, others did not. In addition, recreation time was written as a group activity.
These findings were reviewed with facility staff during the complaint investigation process.
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Plan of Correction
Issue #1
All Group Activities ? therapy, educational and recreational are entered with the same heading. Groups must be able to distinguish between Therapy and Non-Therapy Groups.
Issue #2
Progress Notes ? Not standardized.
All Progress Notes should be in DAP Format.
To ensure that a data collection and record keeping system that allows for the efficient retrieval of data needed to measure our performance in relationship to our stated goals and objectives is in place we will be modifying our Electronic Health Record (EHR) Inpatient Group Service so that all group activities may be distinguished between therapy and non-therapy groups.
A workflow will be developed for the modified Inpatient Group Service as well as the DAP Note format. All applicable staff will be trained by the Director of Main Campus.
The Director of Health Information Management will audit Inpatient Group Services on a weekly basis times three months. Audit results will be forwarded to the Director of Main Campus and copied to the Vice President of Operations for review and appropriate follow-up.
Person's Responsible: Program Director, Clinical Managers, Director of HIM and VP of Operations
Completion Date: July 15, 2020 |
Observations
The facility failed to provide counseling services according to the individual treatment and rehabilitation plan in six of six client records.
Six client records were reviewed on February 26 & March 2, 2020. The treatment plans documented in all six client records stated that clients would have daily group therapy sessions. Client records #1, 2, 3, 4, 5 and 6 did not have documentation of daily group therapy.
Client #1 was admitted into the rehab program on February 4, 2020. The treatment plan was documented on February 7, 2020. The period of February 8-18, 2020 was reviewed. Client #1 did not have group therapy on February 8, 9 & 16, 2020.
Client #2 was admitted into the rehab program on February 10, 2020. The treatment plan was documented on February 11, 2020. The period of February 11-23, 2020 was reviewed. Client #2 did not have group therapy on February 16, 22 & 23, 2020.
Client #3 was admitted into the rehab program on January 22, 2020 and discharged on February 12, 2020. The treatment plan was documented on January 22, 2020. The period of January 26 - February 8, 2020 was reviewed. Client #3 did not have group therapy on January 26, February 1 & 8, 2020.
Client #4 was admitted into the rehab program on September 30, 2019 and discharged on October 23, 2019. The treatment plan was documented on October 2, 2019. The period of October 6 - 19, 2019 was reviewed. Client #4 did not have group therapy on October 6, 8, 9, 10, 11, 12, 14, 17 & 19, 2020.
Client #5 was admitted into the rehab program on September 3, 2019 and discharged on October 1, 2019. The treatment plan was documented on September 4, 2019. The period of September 15 - 28, 2019 was reviewed. Client #5 did not have group therapy on September 15, 18, 21, 24 and 28, 2019.
Client #6 was admitted into the rehab program on January 31, 2020 and discharged on February 20, 2020. The treatment plan was documented on January 31, 2020. The period of February 2 - 15, 2020 was reviewed. Client #6 did not have group therapy on February 6 & 8, 2020.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
709.52 (c ) LICENSURE Provision of Counseling Services
All Treatment Plans stated that clients would have daily group therapy sessions. There was no evidence of daily group therapy sessions
To ensure that counseling services are provided according to the individual treatment and rehabilitation plan we will be modifying our Electronic Health Record (EHR) to be more specific in our group session language and modalities. In addition, the Director of Main Campus will train all staff members on properly completing an individualized and prescriptive treatment plan. This training will focus on ensuring that clients will be provided services that have been prescribed in their treatment and rehabilitation plan.
The Director of Health Information Management will audit Inpatient Group Services and Individualized Treatment Plans on a weekly basis times three months. Audit results will be forwarded to the Director of Main Campus and copied to the Vice President of Operations for review and appropriate follow-up.
Person's Responsible: Program Director, Clinical Managers, Director of HIM and VP of Operations
Completion Date: July 15, 2020
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Observations
The facility failed to provide counseling on a regular and scheduled basis.
Six client records were reviewed on February 26 & March 2, 2020. All six of the clients reviewed were supposed to have group therapy daily. Group therapy sessions were not documented in any of the six client records reviewed in a regular and scheduled basis.
Client record #1 did not have documentation of group therapy for 3 of 11 days.
Client record #2 did not have documentation of group therapy for 3 of 13 days.
Client record #3 did not have documentation of group therapy for 3 of 14 days.
Client record #4 did not have documentation of group therapy for 9 of 14 days.
Client record #5 did not have documentation of group therapy for 5 of 14 days.
Client record #6 did not have documentation of group therapy for 2 of 14 days.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
709.52 (d) LICENSURE Regularity of Counseling Provided
The Facility failed to provide counseling on a regular basis. All six clients were supposed to have group therapy daily. There was no evidence of daily group therapy sessions.
To ensure that counseling and group services are provided on a regular basis we will begin to be more prescriptive in our treatment plans and will be specific in both type and frequency. For example, we will state that the client will participate in individual therapy 1x a week, therapy group 5x a week, and psychoeducational groups and activities daily, as deemed necessary in their individualized plans.
The Director of Health Information Management will audit Counseling Services on a weekly basis times three months. Audit results will be forwarded to the Director of Main Campus and copied to the Vice President of Operations for review and appropriate follow-up.
Person's Responsible: Program Director, Clinical Managers, Director of HIM and VP of Operations
Completion Date: July 15, 2020
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