Observations
The facility failed to ensure that patients received 1 hour of individual psychotherapy per month during the patient 's first 2 years, in seven of seven patient records reviewed on June 19, 2017.
Seven patient records were reviewed. Patient records # 1, 2, 3, 4, 5, 6 and 7 did not document the required 1 hour a month of individual psychotherapy.
Patient # 1- there were no individual sessions documented from November 2016 to June 18, 2017.
Patient # 2- there were no individual sessions documented from September 2016 to June 11, 2017.
Patient # 3- there were no individual sessions documented.
Patient # 4- there were no individual sessions documented for November and December, 2016.
Patient # 5- there were no individual sessions documented for December, 2016.
Patient # 6- there were no individual sessions documented.
Patient # 7- there were no individual sessions documented.
These findings were received with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review the results of the survey with the clinical team on 7/11/17 at staff meeting . The Clinical Supervisor will conduct training on the regulation with the clinical staff at that meetin. Documentation of at least one hour of individual clinical services will be provided monthly for the clients first two years in treatment.The implementation of this will be monitored buy Clinical Supervisor reviewing chart documentation weekly during chart audits and case consultations. |