Observations
Based on the review of client records, the facility failed to assure counseling services were being provided according to the individual treatment and rehabilitation plan in five of seven client records reviewed.
Client # 1 was admitted May 15, 2023 and was active at the time of inspection. The treatment and rehabilitation plan, dated March 19, 2024, indicated the client was to receive weekly individual counseling sessions. There was no documentation in the record of any individual sessions provided to the client from March 21, 2024 through the date of the inspection.
Client #2 was admitted March 16, 2023 and was active at the time of inspection. The treatment and rehabilitation plan, dated February 22, 2024, indicated the client was to receive weekly individual counseling sessions. There was no documentation in the record of any individual sessions provided to the client from March 21, 2024 through the date of the inspection.
Client# 3 was admitted August 21, 2023 and was active at the time of inspection. The treatment and rehabilitation plan, dated February 29, 2023, indicated the client was to receive weekly individual counseling sessions. There was no documentation in the record of any individual sessions provided to the client from March 26, 2023 through the date of the inspection.
Client# 4 was admitted December 12, 2022 and was discharged December 5, 2023. The treatment and rehabilitation plan, dated October 12, 2023, indicated the client was to receive weekly individual counseling sessions. There was no documentation in the record of any individual sessions provided to the client from November 9, 2023 through November 28, 2023.
Client# 6 was admitted July 11, 2022 and was discharged March 6, 2024. The treatment and rehabilitation plan, dated February 21, 2024, indicated the client was to receive weekly individual counseling sessions. There was no documentation in the record of any individual sessions provided to the client from February 21, 2024 through March 6, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor along with the facility director will hold an in-service training with all clinical staff to review treatment/recovery plans timeframes and the importance of clients complying with the plan agreed upon. During the in-service trainings, clinicians will also be reminded that when clients are not in compliance, a contact note is needed to update status of attendance and steps taken to contact client. This training will also include guidelines for PTP within 15 days of admission, CTP within 30 days of admission, and updates every 60 days after. The in-service training will also review the importance of completing and documenting each plan with the client and highlight review and completion dates.
The facility director will also complete weekly reviews of documentation that must be filed along with compliance reports to ensure the completion of clinical documents and that the documents are available for timely reviews. |