Observations
Based on a review of the client records, the facility failed to document progress notes which contained the data and the assessment in six of the eight required records. The data should include information presented by the client during the counseling session, counselor observations and information about the client from other sources. The assessment should include the counselor's analysis of and conclusions regarding the client's current situation or status in 6 of 8 client records.
The findings include:
Eight client records were reviewed on November 23 - 24, 2009. Eight records were required to have progress notes that include the assessment. Six of the eight records, records # 2, 3, 4, 5, 6 and 7, did not include this documentation.
Record #2 was admitted 9-4-09. The group progress notes that do not include an assessment are dated October 8, 2009, October 21, 2009, November 5, 2009, November 12, 2009 and November 19, 2009.
Record #3 was admitted 9-24-09. Individual progress notes that do not include an assessment are dated September 24, 2009, October 8, 2009, and October 26, 2009.
Record #4 was admitted 10-3-09. The group progress notes that do not include an assessment are dated October 8, 2009, October 15, 2009, November 5, 2009 and November 12, 2009. These same group progress notes also do not include the data which should include information presented by the client during the counseling session, counselor observations and information about the client from other sources.
Record #5 was admitted 5-26-09 and discharged 11-19-09. The group progress notes that do not include an assessment are dated June 4, 2009, September 24, 2009 and October 8, 2009. An individual progress note did not include a clinical assessment for a progress note dated June 5, 2009.
Record #6 was admitted 8-7-09 and discharged 10-19-09. The group progress notes that do not include an assessment are dated August 29, 2009 and September 28, 2009. Individual progress notes did not include a clinical assessment for progress notes dated August 7, 2009, August 14, 2009, August 21, 2009, September 25, 2009, and October 5, 2009.
Record #7 was admitted 8-14-09 and discharged 9-25-09. Individual progress notes did not include a clinical assessment for progress notes dated August 14, 2009 and August 21, 2009.
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Plan of Correction
A new clinical group feedback sheet was developed on 11/20/09. The Program Supervisor will train all staff on completing clinical group notes properly on 12/11/09. At that same training the Program Suupervisor will train all staff on writing individual session notes that contain effective "assessments". This will be monitored by the Program Supervisor, Division Director and through the monthly UR/QI meetings. |