Observations
The facility failed to document treatment plan updates within the regulatory timeframe in three of seven client records reviewed.
Client #4 was admitted on 4/17/18 and was discharged on 7/31/18. A treatment plan update was completed on 4/23/18 and the next update was due no later than 6/23/18; however, there was no updates documented in the record at the time of the inspection.
Client #5 was admitted on 3/13/18 and was discharged on 7/31/18. A treatment plan update was completed on 3/19/18 and the next update was due no later than5/19/18 however, there was no updates documented in the record at the time of the inspection.
Client #6 was admitted on 3/20/18 and was discharged on 7/3/18. A treatment plan update was completed on 4/4/18 and the next update was due no later than 6/4/18; however, there was no updates documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will review treatment planning with all clinical staff during individual and group supervision. Staff will complete a master treatment plan with the client by the 3rd session and update the treatment plan every 60 days. Notes will be added to the client record to document the absence of the client or any gaps in treatment due to short term issues, i.e. inpatient treatment or incarceration. Clinical staff will obtain client signature on treatment plan update upon the clients return to treatment. Clinical supervisor will review client records to ensure treatment plans are created by the 3rd session and are being updated every 60 days. Deficiencies will be reviewed with the appropriate staff by the clinical supervisor. The facility will be in full compliance by 10/1/2018 |
Observations
The Facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in three of seven records reviewed.
Client #3 was admitted on 6/26/18 and was still active at the time of the inspection. The comprehensive treatment plan, dated 7/3/18, indicated 1 weekly individual session. The chart's record of service and progress notes indicated that the client had received no individual sessions the week of 7/8-7/14, 7/15-7/21,7/29-8/4, 8/5-8/11 and 8/12-8/18.
Client #5 was admitted on 3/13/18 and was discharged 7/31/18. The comprehensive treatment plan, dated 3/19/18,indicated 1 weekly individual session. The chart's record of service and progress notes indicated that the client had received no invidiously sessions the weeks of 4/1-4/7, 4/29-5/5, 5/6-5/12, 5/20-5/26, 5/27-6/2, 6/3-6/9, 6/17-6/23,6/24-6/30, 7/1-7/7 and 7/15-7/21.
Client #6 was admitted on 3/20/18 and was discharged 7/3/18. The comprehensive treatment plan, dated 4/4/18,indicated 1 weekly individual session. The chart's record of service and progress notes indicated that the client had received no invidiously sessions the weeks of 4/22-4/28, 6/10-6/16 and 6/17-6/23.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor will review the requirement to document in the treatment plan the type of treatment, frequency and length of session with clinical staff during individual and group supervision by 10/1/18. Clinical supervisor will review active client records weekly through the electronic medical record services submitted by clinical staff and provide increased feedback as necessary. Clinical staff will document the absence of the client through a collateral note in the client record when an appointment is cancelled or the client does not show for their session. Clinical staff will update treatment plans to reflect any change in frequency of sessions as clients needs change. Director of Substance Abuse Services will meet with the clinical supervisor weekly to discuss compliance and review client records. The facility will be in full compliance by 10/1/2018. |