Observations
Based on a review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client #1 was admitted on August 1, 2023 and was active at the time of inspection. A treatment plan update dated November 27, 2023, indicated the client was to receive weekly individual counseling sessions. There was no documentation in the record of service or progress notes that individual counseling sessions occurred during the weeks of January 4, 2024 through the date of the inspection.
Client #2 was admitted on November 14, 2023 and was active at the time of inspection. A treatment plan update dated November 21, 2023, indicated the client was to receive weekly individual counseling sessions. There was no documentation in the record of service or progress notes that individual counseling sessions occurred during the weeks of January 5, 2024 through the date of the inspection.
Client #3 was admitted on November 17, 2023 and was active at the time of inspection. A treatment plan update dated November 21, 2023, indicated the client was to receive weekly individual counseling sessions. There was no documentation in the record of service or progress notes that individual counseling sessions occurred during the weeks of January 5, 2024 through the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to assure that documentation of counseling services were updated as to the inspection date for three of the seven client records reviewed. There was no documentation in the record of service or progress notes that individual counseling sessions occurred during the weeks of January 4, 2024 through the date of the inspection for client #1. There was no documentation in the record of service or progress notes that individual counseling sessions occurred during the weeks of January 5, 2024 through the date of the inspection for client #2. There was no documentation in the record of service or progress notes that individual counseling sessions occurred during the weeks of January 5, 2024 through the date of the inspection for client #3. Clinical supervisor will update the policy to state counselors will have three weeks to enter clinical notes. This will ensure current documentation that aligns with the individual treatment and rehabilitation plan. This will be done through staff training and regular file checks and will be implemented by 2/29/2024. |