Observations
Based on the review of the client records, the facility failed to document individual counseling sessions on the record of service in three of five client records.
The findings include:
Five client records from the inpatient non-hospital - residential treatment and rehabilitation activity were reviewed on November 20, 2012. The record of service documentation was required in five client records. The facility did not document the individual counseling sessions on the record of service in client records #1, #2, and #5.
Client record # 1- The client was admitted October 24, 2012. The record of service did not include documentation of some individual counseling sessions provided to the client. Progress notes documented that individual counseling sessions occurred on October 24, 2012, October 26, 2012 and November 2, 2012, but there was no entry of these services on the record of service.
Client record # 2- The client was admitted October 31, 2012. The record of service did not include documentation of an individual counseling session provided to the client. A progress note documented that an individual counseling session occurred on November 15, 2012 but there was no entry of this service on the record of service.
Client record # 5- The client was admitted October 10, 2012. The record of service did not include documentation of an individual counseling session provided to the client. Progress notes documented that individual counseling sessions occurred on October 11, 2012, October 16, 2012, October 19, 2012, October 29, 2012, November 8, 2012, but there was no entry of these services on the record of service.
This was discussed with and confirmed by the supervisor on November 20, 2012.
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Plan of Correction
Program Supervisor will review clinical documentation requirements for the record of service with all clinical staff in the next scheduled staff meeting in january 2013.
Program Supervisor will monitor the completion of the record of service in the agency monthly QI/UR meetings. |