Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in three of nine client records reviewed.
The findings include:
Nine client records requiring documentation of the completion of individualized treatment and rehabilitation plans were reviewed on 03/04/2016. Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in three of nine clients' records reviewed.
Client #7's individualized treatment plan, dated 01/21/2016, read that the client was to receive individual counseling once a week, but from the date of the treatment plan, the client only received individual counseling on 02/23/2016. Client #7 was an active client at the time of the onsite inspection.
Client #8's individualized treatment plan, dated 11/24/ 2015, reads that the client was to receive individual counseling once a week, but from the date of the treatment plan, the client only received individual counseling on 12/01/2015, and 12/15/2015. Client #8 was an active client at the time of the onsite inspection.
Client #10's individualized treatment plan, dated 11/16/ 2015, reads that the client was to receive individual counseling once a week, but from the date of the treatment plan, the client only received individual counseling on 12/03/2015, 12/17/2015, 2/05/2016 and 2/23/2016. Client #10 was an active client at the time of the onsite inspection.
The findings were reviewed with facility staff during the inspection process.
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Plan of Correction
At treatment meeting on March 21, 2016 clinical supervisor reviewed with counselors Standard 709.92 (a) (2) Treatment and rehabilitation services. Discussion included counselors needing to document on client service log when frequency of counseling sessions attended doesn't match frequency of sessions recommended on treatment plan. Counselors will document if client was a No Show, Cancelled or Rescheduled an appointment.
If there are gaps in client attendance with no communication as to why, counselors will attempt to contact client, via phone or mail to address this issue and document on service log the contact.
Client #7-During recent counseling session counselor and client discussed past gaps in client's attendance and not following treatment plan frequency of sessions. Treatment plan frequency was revised, plan was signed by client and counselor to reflect new frequency of treatment.
Client #8-Clinical supervisor discussed with counselor status of Client #8. Client has not attended sessions for six weeks. Counselor has made two attempts to contact client to discuss non-attendance. Counselor will send discharge letter notifying client of pending discharge if client does not schedule and attend counseling session. If client does not schedule another appointment counselor will do administrative discharge. If client schedules and attends, treatment plan will be revised to reflect new treatment frequency.
Client #10-During counseling session counselor and client discussed past gaps in client's attendance and not following treatment plan frequency of sessions. Treatment plan frequency was revised, plan was signed by client and counselor to reflect new frequency of treatment.
During client file review clinical supervisor monitors closely client service log entries to insure treatment frequency is being provided according to treatment plan. Facility will be in full compliance with standard by April 30, 2016.
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