Observations
The facility failed to document an individual treatment plan that included the frequency of treatment and rehabilitation services in six of seven client records reviewed on April 18, 2018.
Client # 1 was admitted on September 14, 2017. The individual treatment plan was documented on October 9, 2017.
Client # 3 was admitted on November 1, 2017. The individual treatment plan was documented on November 29, 2017.
Client # 4 was admitted on September 5, 2017 and discharged on January 16, 2018. The individual treatment plan was documented on October 4, 2017.
Client # 5 was admitted on November 1, 2017 and discharged on March 2, 2018. The individual treatment plan was documented on November 29, 2017.
Client # 6 was admitted on June 30, 2017 and discharged on December 8, 2017. The individual treatment plan was documented on July 27, 2017.
Client # 7 was admitted on May 1, 2017 and discharged on August 24, 2017. The individual treatment plan was documented on May 26, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will provide training to counseling staff on treatment plan documentation on April 25,2018. This training will review appropriate frequency and duration of individual and group sessions for the clients served in this clinic. The training will detail how to document client no shows and gaps in treatment. The training will reinforce the importance of consistent sessions. The training will remind counselors that counseling services are to be provided according to the individual treatment and rehabilitation plan.
Individual treatment and rehabilitation plans, records of service and progress notes will be reviewed monthly in order to ensure that the counselors are documenting services as stated in the treatment plan. Reviews of the record will be conducted by the clinical supervisor. All treatment records from April 25, 2018 will be in compliance.
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