Observations
Based on the review of the client records, the facility failed to document individual counseling sessions on the record of service in six of eleven client records.
The findings include:
Thirteen client records were reviewed on May 25, 2011. The record of service documentation was required in eleven client records. Two clients were only recently admitted. The facility did not document the individual counseling sessions on the record of service in client records #3, #7, #8, #10, #11, and #13.
Client #3 was admitted to treatment on 5-2-11. The record of service did not include documentation of the individual counseling sessions provided to the client. Progress notes documented that individual counseling sessions occurred on 5-2-11, and 5-9-11, but there are no entries of these services on the record of service.
Client # 7 was admitted to treatment on 4-28-11. The record of service did not include documentation of an individual counseling session provided to the client. Progress notes documented that an individual counseling session occurred on 5-23-11, but there was no entry of this service on the record of service.
Client #8 was admitted to treatment on 5-10-11. The record of service did not include documentation of the individual counseling sessions provided to the client. Progress notes documented that individual counseling sessions occurred on 5-10-11, 5-13-11, and 5-19-11, but there was no documentation of these services on the record of services.
Client #10 was admitted to treatment on 2-16-11. The record of service did not include documentation of the individual counseling sessions provided to the client. Progress notes documented that individual counseling sessions occurred on 2-16-11, 2-21-11, 2-25-11, 3-11-11, 3-24-11, 4-6-11, and 4-20-11, but there was no documentation of these services on the record of service. There were no progress notes or record of service entries documenting individual sessions for this client since 4-20-11.
Client #11 was admitted to treatment on 3-10-11. The record of service did not include documentation of the individual counseling sessions provided to the client. Progress notes documented that an individual counseling session occurred on 3-14-11, but there was no documentation of this service on the record of service. There were no progress notes or record of service entries documenting individual sessions for this client since 3-14-11.
Client #13 was admitted to treatment on 3-3-11. The record of service did not include documentation of the individual counseling sessions provided to the client. Progress notes were documented for an individual counseling session that occurred on 5-19-11, but there was no entry of this service on the record of service.
This was discussed with the facility director on May 25, 2011 at approximately 1:30 PM. The director confirmed that the individual sessions were not included on the record of service.
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Plan of Correction
All case files are reviewed monthly by the Clinical Supervisor and overseen by the Division Director in the monthly PI/QI meeting. These files belong to one particular counselor who is on a progressive disciplinary action plan and will begin having weekly supervision with the Clinical Supervisor. This supervision will include reviewing 4 files each week to insure all clinical documentation is timely, accurate and in the file. The supervision and the progressive disciplinary action is being overseen by the Division Director to insure that all client files meet the licensing standards. |