Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of four records reviewed.
Client # 1 was admitted on 5/27/22 and was discharged on 11/3/22. The treatment plans dated from 7/15/22 -10/26/22 indicated individual sessions were to occur weekly. Documentation of individual sessions was missing for the weeks of 7/17-8/13, 8/21-9/3 and 9/11-10/29/22.
Client # 2 was admitted on 8/11/22 and discharged on 11/21/22. The treatment plans dated from 8/11/22 - 11/15/22 indicated individual sessions were to occur weekly. Documentation of individual sessions was missing for the weeks of 8/18-10/1, 10/9-10/15,10/23-10/29 and 11/6-11/21/22.
Client # 3 was admitted on 8/23/22 and was discharged on 12/21/22. The treatment plans dated from 8/23/22 - 12/23/22 indicated individual sessions were to occur weekly. Documentation of individual sessions was missing for the weeks of 9/11 - 10/29 and 11/27-12/31/22.
Client # 4 was admitted on 7/22/22 and was discharged on 11/10/22. The treatment plans dated from 7/22/22 - 10/28/22 indicated individual sessions were to occur weekly. Documentation of individual sessions was missing for the weeks of 7/31 - 8/6, 9/25-10/8 and 10/30-11/5/22.
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Plan of Correction
1) All Treatment services will be delivered and documented according to the individual treatment plan.
2) Individual supervision will be held with each clinical staff member to review 709.52 (c) regarding following the treatment plan in conducting weekly individual sessions and documenting progress notes in the electronic health record. This will be documented in a supervision note.
3) If, for any reason, a client is unable to attend a session, such as when they are away from the facility for an extended time, a weekly independent note will be entered into the chart documenting the reason services were not provided according to the treatment plan.
4) The Clinical Supervisor will conduct bi-weekly audits of active charts to ensure that services are documented according to the treatment plan. Any missing documentation will be discussed with the counselor and documented in clinical supervision notes. Any corrections needed will be completed within 48 hours.
5) The Quality Assurance Manager will conduct regular quarterly audits of clinical charts, including specific review of any plan of correction items, and will review all findings with program management. Any areas of concern will be summarized in a report and addressed in a performance improvement plan. |