Observations
Based on a review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in two of ten client records reviewed.
The findings include:
Ten client records were reviewed for counseling services on 5/18/2015. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records # 2, and 3.
Client #2 was admitted to treatment on 5/30/2014 with a discharge date of 12/11/2014. Client record # 2 contained a treatment plan dated 7/3/2014 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks of 8/11/2014, 8/18/2014, 9/1/2014 or 9/8/2014.
Client #3 was admitted to treatment on 7/30/2014 with a discharge date of 4/16/2015. Client record #3 contained a treatment plan dated 12/18/2014 that identified the counseling services to be provided as individual therapy sessions 1 time every other week. There were no individual therapy sessions scheduled for the client the weeks of 12/1/2014, 1/19/2015, or for the month of February.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training will be held on June 19, 2015 to address clinical staff on treatment management procedures specific to assuring that counseling services are provided according to the individual and treatment plan updates. All staff will be directed to schedule clients according to their treatment recommendation and document weekly on the client record of service. Any deviation from the set course of treatment will also be documented on the record of service. The Clinical Supervisor will review treatment plans recommendations and compare it to the record of service for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions.
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