Observations
Based on an onsite complaint investigation, client record #1 was reviewed. The facility failed to provide client #1 with counseling on a regular and scheduled basis.
The findings include:
An onsite complaint investigation was conducted on March 29, 2011 and client record #1 was reviewed. Client #1 was admitted to treatment on December 30, 2010. As part of the outpatient treatment activity, the client is required to attend one hour of individual counseling and one and a half hours of group counseling per week.
Client #1 was offered and/or provided individual counseling sessions on 1/6/11, 2/7/11 and 2/14/11. The individual counseling sessions that were scheduled on 1/13/11 and 1/31/11 were cancelled by the counselor. There was no documentation that any efforts were made to reschedule the cancelled sessions nor was there any documentation that the client was offered the opportunity to see another counselor on those days.
A progress note dated 1/13/11 stated that the client was to attend the next individual session which was to be held on 1/20/11; however, there was no documentation stating that this session was offered.
In summary, no individual counseling sessions were completed and/or offered to client #1 for the weeks of January 2-8, 9-15, 16-22, 23-29 and January 30 - February 2, 2011.
Group counseling sessions were offered/provided weekly as required.
An interview with the clinical supervisor and facility director was conducted on March 29, 2011. It was confirmed that the individual sessions scheduled for 1/13/11 and 1/31/11 were cancelled by the counselor and no additional documentation was available to show efforts to reschedule the sessions were made. It was also confirmed that there was no documentation to show that an individual counseling session was offered/scheduled on 1/20/11.
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Plan of Correction
Renewal Treatment Inc. (RTI) shall provide counseling on a regular and scheduled basis. RTI Counselors have recieved instruction and training on this requirement and shall follow this directive. RTI Counselors are required to notify the Clinical Supervisor; and in their absence, Program Director prior to cancelling any treatment sessions. RTI Counselors shall provide clients with either the oppurtunity to see another Counselor on the same day as the cancelled session or will reschedule the cancelled session according to treatment planning requirements. RTI Counselors shall document; in the client file, when a scheduled session has to be cancelled and how and when it was rescheduled. The Clinical Supervisor and Program Director shall ensure compliance with this POC. This POC is in place. |