Observations
Based on the review of client records, the facility failed to provide counseling to clients on a regular and scheduled basis.
The findings included:
Ten client records were reviewed on October 1, 2015. The facility failed to document that counseling was provided on a regular and scheduled basis in client records #1, 2 and 4.
Client #1 was admitted on July 7, 2014 and discharged on January 5, 2015. The facility did not document individual sessions for November 2014.
Client #2 was admitted October 15, 2014 and discharged on January 7, 2015. The facility did not document individual sessions for November 2014.
Client #4 was admitted November 4, 2014 and discharged on March 19, 2015. The facility did not document individual sessions for the months of December 2014, January 2015 and March 2015.
These findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
"Counseling shall be provided to a client on a regular and scheduled basis" (709.52(d)).
Counselors will provide counseling on a regular basis and adhere to the type and frequency as noted on the client treatment plan. Counselors will promptly document counseling services on the appropriate form and ensure all counseling services are recorded on the MONTHLY RECORD OF SERVICES PROVIDED sheet contained in the client case file. The Clinical Supervisor and Program Director will review regulation 709.52 and facility procedural expectations with the clinical staff in a clinical meeting on Thursday, October 29, 2015 and will obtain written verification that the policies were reviewed and understood. The Clinical Supervisor will ensure compliance by conducting monthly chart audits and supervision with the counselors. |