Observations
Based on the review of the client records, the facility failed to document individual counseling sessions on the record of service in five of six client records.
The findings include:
Six client records were reviewed on July 16, 2012. The record of service documentation was required in six client records. The facility did not document the individual counseling sessions on the record of service in client records #1,#2, #3, #4 and #5.
Client record # 1- The client was admitted April 9, 2012. The record of service did not include documentation of an individual counseling session provided to the client. Progress notes documented that an individual counseling session occurred on April 10, 2012 and April 24, 2012, but there is no entry of this service on the record of service. In addition, the record of service for the week of May 21-27, 2012 was missing from the client record.
Client record # 2- The client was admitted April 10, 2012. The record of service did not include documentation of an individual counseling session provided to the client. Progress notes documented that an individual counseling session occurred on May 22, 2012, June 22, 2012 and June 28, 2012 but there were no entries of these services on the record of service. In addition, the record of service for the weeks of April 10-15, 2012, April 16-22, 2012, April 23-29, 2012, April 30-May 6, 2012, May 7-13, 2012, May 14-20, 2012, May 28-June 3, 2012, June 4-10, 2012, and June 11-17, 2012 were missing from the client record.
Client record # 3- The client was admitted March 21, 2012. The record of service did not include documentation of an individual counseling session provided to the client. Progress notes documented that an individual counseling session occurred on May 7, 2012 and June 1, 2012, but there were no entries of these services on the record of service.
Client record # 4- The client was admitted March 1, 2012, and was discharged on June 12, 2012. The record of service did not include documentation of the individual counseling sessions provided to the client. Progress notes documented that individual counseling sessions occurred on April 26, 2012, May 10, 2012 and May 15, 2012, but there were no entries of these services on the record of service. In addition, there was a discrepancy on the date of an individual progress note dated April 12, 2012 and an entry on the record of service for an individual session on April 13, 2012.
Client record # 5- The client was admitted March 15, 2012. The record of service did not include documentation of an individual counseling session provided to the client. Progress notes documented that an individual counseling session occurred on March 29, 2012, April 2, 2012 and April 12, 2012, but there were no entries of this service on the record of service.
This was discussed with and confirmed by the clinical supervisor on July 16, 2012.
|
Plan of Correction
The Halfway House Program Manager will provide oversight and management to ensure that all individual counseling sessions are accurately documented on the record of service.
The Halfway House Clinical Supervisor will review the record of service on a monthly basis to ensure that individual counseling sessions are accurately documented on the record of service, and will provide supervision and training to the Individual Therapists about accurate and timely documentaion of services rendered on the record of service.
The Individual Therapists will complete the record of service to accurately reflect all individual counseling sessions by the end of each week and will file the record of service in the client's chart.
The Program Manager will review closed records to check for compliance and will address non-compliance issues immediately.
The Halfway House will be in full compliance by 8/12/12. |