Observations
The residential facility failed to enter progress notes into client records after each significant contact. Based on the review of three active client records and an interview with the facility director on May 29, 2008, client records failed to include progress notes after each significant contact.
Client record # 1 - Admitted April 9, 2008. Last group note entry dated May 5, 2008. Group counseling scheduled weekly. No group note entry for sessions scheduled on May 12, 2008 and May 19, 2008.
Client record # 2 - Admitted on March 5, 2008. Last group note entry dated May 5, 2008. Group counseling scheduled weekly. No group note entry for sessions scheduled on May 12, 2008 and May 19, 2008.
Client record # 3 - Admitted on January 24, 2008. Last group note entry dated May 5, 2008. Group counseling scheduled weekly. No group note entry for sessions scheduled on May 12, 2008 and May 19, 2008.
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Plan of Correction
Groups will be conducted at least one time per week and notes will be completed and entered in the client record after each significant contact. Clinical director reviewed this procedure with clinical staff on 5/18/2008 and all clinical staff has signed-off that they have reviewed the procedure. Files will be reviewed on a monthly basis by clinical director to ensure compliance with this policy. |