Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in four of five client records. Client #2 was admitted to the outpatient level of care on March 15, 2023 and was active at the time of review. Client #2 ' s record contained a treatment and rehabilitation plan that indicated one group session was to be conducted each week, as well as one individual session each month. Client #2 ' s record did not contain documentation a group session occurred during the weeks of May 1, 2023, through May 5, 2023. The record did not contain documentation of an individual session occurred during the month of April 2023. Client #3 was admitted to the outpatient level of care on December 28, 2022 and was active at the time of review. Client #3 ' s record contained a treatment and rehabilitation plan that indicated one group session was to be conducted each week, as well as one individual session each month. Client #3 ' s record did not contain documentation an individual session occurred during the month of April 2023. Client #4 was admitted to the outpatient level of care on November 24, 2021 and was discharged on February 1, 2023. Client #4 ' s record contained a treatment and rehabilitation plan that indicated one group session was to be conducted on a bi-weekly basis. Client #4 ' s record did not contain documentation that any group session occurred between January 4, 2023, and February 1, 2023. Client #5 was admitted to the outpatient level of care on November 16, 2022 and was discharged February 22, 2023. Client #5 ' s record contained a treatment and rehabilitation plan that indicated one group session was the be conducted each week, as well as one individual session each month. Client #5 ' s record did not contain documentation that an individual session occurred during the month of January 2023. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Observation #1885 which occurred in the Plum office on 5/23/2023 was discussed with all staff in staff meeting on June 13, 2023 to ensure that all counseling services are provided in accordance with DDAP regs.
Agency treatment planning will be sure that counseling services match/follow the individual treatment and rehabilitation plan.
Treatment Supervisor will review patient charts weekly for compliance accuracy.
Clinical Supervisor will review treatment plan updates with Therapists to ensure accuracy for adherence to services rendered and documentation.
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