Observations
Based on a review of the client records, the facility failed to provide documentation of a complete record of service that included accurate dates of service.
The findings include:
Ten client records were reviewed on July 17, 2013, and all ten client records were required to include a complete and accurate record of service. The facility failed to provide an accurate and complete record of services in four of the ten client records, # 1, 3, 5, and 8.
Record # 1 - Client was admitted to treatment on 12-31-2012 and was discharged on 7-10-2013. An individual session progress note was documented for 2-8-2013, but the individual session was not documented on the record of service.
Record # 3 - Client was admitted to treatment on 1-31-2013 and was discharged on 6-7-2013. An individual session progress note was documented for 2-19-2013, but the entry for the individual session was documented on the record of service as 2-20-2013.
Record # 5 - Client was transferred from intensive outpatient to outpatient treatment on 3-1-2013 and was discharged on 6-5-2013. A group session progress note was documented for 3-12-2013, but the entry for the group session was documented on the record of service as 3-13-2013. A group session progress note was documented for 5-14-2013, but the entry for the group session was documented on the record of service as 5-15-2013.
Record # 8 - Client was admitted to treatment on 5-14-2013. A group session progress note dated 7-1-2013 documented the client was absent/no call and was signed by one therapist. The record of service entry for 7-1-2013 documents the group session as completed for 1.5 hours by another therapist.
The findings were reviewed with the director and were not disputed.
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Plan of Correction
The clinical director conducted a clinical staffing on 7/31/13 to review charting. All clinicians were educated on the importance of making sure that all dates of service logged agree with all treatment records, group notes etc. Effective immediately all clinical staff are required to check and double check said dates and counselor will be held responsible for any discrepancies. |