Observations
Based on a review of six client charts on July 28, 2021, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in client chart #6.
Client #6 was admitted on August 13, 2019 and is still an active client. According to the treatment plan client #6 was to receive four hours of individual counseling each month. There were no individual counseling notes observed in the client chart #6 for October, November and December of 2020 and for January and February of 2021.
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Plan of Correction
As of 8/30/21, The Program Director shall complete a internal audit of the individual counseling sessions every 2 weeks. The program director will run the Patients not counseled report within the Electronic Medical Record to identify missed sessions. A copy of the report shall be given to the counseling staff to follow-up on. Copies of the DAP notes and the non-billable notes for missed sessions shall be kept in the EMR for review The audit and review system will be ongoing by the program director |