Observations
An on-site follow-up incident investigation was conducted on September 23, 2016. Based on the investigation it was determined that the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan.
The record of the client involved in the incident was reviewed. The client's intial treatment plan dated 3/31, the client's comprehensive treatment plan dated 4/30, and the client's updated treatment plan dated 6/29, all indicated the client would receive one individiual and one group per week.
During the weeks of 4/7, 4/21, 5/5, 5/12, 5/19, 5/26, 6/2,6/9,6/16, 6/30 and 7/7 the client did not recieve treatment as indicated in the treatment plan.
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Plan of Correction
An all staff in service reminder training will be held on December 9, 2016 to address clinical staff on treatment management procedures specific to assuring that counseling services are provided according to the individual and treatment plan updates. All staff will be directed to schedule clients according to their treatment recommendation and document weekly on the client record of service. Any deviation from the set course of treatment will also be documented on the record of service. The Clinical Supervisor as well as the Division Director will review treatment plans recommendations and compare it to the record of service for compliancy during the monthly CQI & Team Management meetings. Clinical staff will be monitored monthly in regular supervisory sessions as well as weekly during clinical meeting. |