Observations
Based upon the review of client records and an interview with the clinical supervisor,both conducted on December 7, 2009 the facility failed to document a treatment plan to include type and frequency of treatment and rehabilitation services in three of six client records.The findings include:Six client records were reviewed on December 7, 2009. Type and frequency of treatment and rehabilitation services was required in all six records. The facility did not document a treatment plan to include type and frequency of treatment and rehabilitation services in client records 1, 3 and 5.An interview with the facility's clinical supervisor was conducted on December 7, 2009. The clinical supervisor confirmed that the identified client records did not include type and frequency of treatment services. She also confirmed that it was their policy to document type and frequency of treatment services on the treatment plans.
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Plan of Correction
The clinical supervisor will hold a two part staff training no later than 2/15/10 regarding the following essential elements of treatment planning. Special emphasis will be made regarding documentation of the type and frequency of treatment sessions on the treatment plan and the provision of counseling services according to the individual treatment on the rehabilitation plan. Counselors will also be instructed to complete an identifiable chart log on each client indicating the date and type of each service completed. The logs will also indicate the date of any client no shows, cancellations or rescheduled sessions. The training will be provided by the Clinical Supervisor and will be supervised by the program director.
Treatment planning Part 1:
Date of admission
Date of initial treatment plan
Date of present treatment plan
Date of subsequent treatment plan
DSM-IV five (5) axes diagnosis
Type and frequency of treatment and rehabilitative services
Behaviorally defined problem statement (based on client complaint, referral sources, narratives, significant others, results of drug tests)
Measurable long and short term treatment goals (should be adjusted to client's current clinical status, revised frequently or as needed)
Proposed types of support service are identified.
Interdisciplinary treatment approach
Treatment Planning Part 2
Consumer involvement in formulation of TX plan (reflects that client understands the nature of treatment with signature).
Methods of treatment are noted (CBT, motivational intervention, problem solving, values clarification, supportive/confrontation, psycho-education, case management/referral/follow-up, role playing/behavioral, skill building/assertiveness, anger management, stress management, role of spirituality
Interventions are specified (Action steps are specified, and are clearly follow up in progress notes)
Staff responsibility for interventions (make reference to who does what)
Consumer strengths and barriers
Statement of understanding is present on treatment plan
TX plans are signed by all treatment team members
Statement of progress on updated TX plans (indicate when goal is revised and/or not achieved, document why client does not attend group.
Treatment plans are legible
Treatment plans are completed within policy timeframe.
The auditing team, which includes the clinical supervisor and program director, will continue to conduct random chart audits on a bi-weekly basis and ensure that treatment plans include type and frequency of treatment and rehabilitation services.
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Observations
Based upon the review of client records and an interview with the clinical supervisor,both conducted on December 7, 2009 the facility failed to document counseling services provided according to the individual treatment plan in six of six client records. The findings include:Six client records were reviewed on December 7, 2009. Documentation of counseling services provided according to the treatment plan was required in all six records. The facility did not document counseling services according to the treatment plan in client records # 1, 2, 3, 4, 5 and 6. In client record # 2, the treatment plan dated 9/14/09 states individual counseling sessions two times weekly, but at the time of review, individual counseling sessions were only documented on September 14, 16, 21 and 23. In client record # 4, the treatment plan dated 9/18/09 states individual counseling sessions three times weekly, but at the time of review, individual counseling sessions were only documented on September 18, 24, 25, 30, October 2, 7, 22, November 4, 5 and 6. In client record # 6, the treatment plan dated 9/18/09 states individual counseling sessions two times weekly, and group sessions one time weekly, but at the time of review, individual counseling sessions were only documented on September 18, 23, 30, October 2, 7, 14, 16, November 5, 13, 17, 20. Only one group sessions note was documented on October 9. The treatment plans in client records # 1, 3 and 5 did not document type and frequency of treatment and rehabilitation services, so it was not possible to determine if counseling was being provided according to the treatment plan.An interview with the facility's clinical supervisor was conducted on December 7, 2009. The clinical supervisor confirmed that the identified client records did not document counseling services provided according to the individual treatment plan .
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Plan of Correction
The supervisor will hold a two part staff training no later than 2/15/10 regarding the following essential elements of treatment planning. Special emphasis will be made regarding documentation of the type and frequency of treatment sessions on the treatment plan and the provision of counseling services according to the individual treatment on the rehabilitation plan. Counselors will also be instructed to complete an identifiable chart log on each client indicating the date and type of each service completed. The logs will also indicate the date of any client no shows, cancellations or rescheduled sessions. The training will be provided by the Clinical Supervisor and will be supervised by the program director.
Treatment planning Part 1:
Date of admission
Date of initial treatment plan
Date of present treatment plan
Date of subsequent treatment plan
DSM-IV five (5) axes diagnosis
Type and frequency of treatment and rehabilitative services
Behaviorally defined problem statement (based on client complaint, referral sources, narratives, significant others, results of drug tests)
Measurable long and short term treatment goals (should be adjusted to client's current clinical status, revised frequently or as needed)
Proposed types of support service are identified.
Interdisciplinary treatment approach
Treatment Planning Part 2
Consumer involvement in formulation of TX plan (reflects that client understands the nature of treatment with signature).
Methods of treatment are noted (CBT, motivational intervention, problem solving, values clarification, supportive/confrontation, psycho-education, case management/referral/follow-up, role playing/behavioral, skill building/assertiveness, anger management, stress management, role of spirituality
Interventions are specified (Action steps are specified, and are clearly follow up in progress notes)
Staff responsibility for interventions (make reference to who does what)
Consumer strengths and barriers
Statement of understanding is present on treatment plan
TX plans are signed by all treatment team members
Statement of progress on updated TX plans (indicate when goal is revised and/or not achieved, document why client does not attend group.
Treatment plans are legible
Treatment plans are completed within policy timeframe.
The auditing team, which includes the clinical supervisor and program director, will continue to conduct random chart audits on a bi-weekly basis to ensure the date of client no shows, cancellations or rescheduled sessions is being documented on the service log of each client record.
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