Observations
The facility failed to assure that clients received the required counseling services according to the individual's comprehensive treatment plan in three of seven client records reviewed.
Client #1 was admitted on November 26, 2018 and was still active at the time of the inspection. The comprehensive treatment plan, dated December 6, 2018, indicated the client was to receive three group therapy sessions per week (twelve group sessions per month). The chart's record of service and progress notes indicated that the client had received two sessions for the week of December 10-December 16, two sessions for the week of December 17-December 23, one session for the week of December 24-December 30, one session for the week of December 31-Janaury 6, 2019, one session for the week of January 14-January 20, 2 sessions for the week of January 21-January 27, two sessions for the week of January 28-February 3, and one session for the week of February 4-February 10.
Client #3 was admitted on January 4, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated January 14, 2019, indicated the client was to receive three group therapy sessions per week (twelve group sessions per month). The chart's record of service and progress notes indicated that the client had received two sessions for the week of January 28-February 3, 2019, and 2 group sessions for the week of February 4-February 10, 2019.
Client #6 was admitted on August 3, 2018 and was discharged on November 11, 2019. The comprehensive treatment plan, dated August 13, 2019, indicated the client was to receive three group therapy sessions per week (twelve group sessions per month). The chart's record of service and progress notes indicated that the client had received one session for the week of September 3-September 9, two sessions for the week of September 17-September 23, zero sessions for the week of October 1-October 7, two sessions for the week of October 8-October 14, and zero sessions for the week of October 22-October 28.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) Rehab Supervisor completed immediate review of record of service. Identified missing records of service and review of the current electronic system in use, it has been noted that the counselor was not using the roster system and therefore was not noting when a client was not present in treatment and for what reason. Reviewed in training with the counselor the importance of documenting the frequencies of attendance, no shows, and cancellations.
2)The counselor will immediately begin using the roster system to track attended, cancelled, and no show services or lack thereof. He will add existing clients by 2/20/19 and add new clients as they are admitted.
3)The attendance policy and level of care requirements have been reviewed with the counselor and he will begin to enforce attendance of three times per week at the IOP level of care, beginning the week of 2/18/19. He will request phone calls from clients if they are unable to attend and he will document all calls in call logs. If a client is not meeting the required number of sessions, he or she will be moved to a different and appropriate level of care.
4) Rehab Supervisor will have weekly reviews of group roster to ensure that the counselor is updating daily if needed and holding clients to the attendance policy.
5) Rehab Supervisor will hold monthly trainings on the completeness of client files and look for deficiency in attendance tracking with all clients. |
Observations
The facility failed to document a complete client record, which is to include case consultation notes and follow-up information in four of seven client records reviewed.
Client #4 was admitted on June 13, 2017 and was dishcarged on November 5, 2017. The client record did not contain documentation of any post-discharge follow up information.
Client #5 was admitted on May 23, 2017 and was discharged on August 27, 2017. The client record did not contain documentation of case consultation notes and post-discharge follow up information.
Client #6 was admitted on August 3, 2018 and was discharged on November 11, 2018. The client record did not contain documentation of case consultation notes and post-discharge follow up information.
Client #7 was admitted on February 16, 2018 and was discharged on May 29, 2018. The client record did not contain documentation of case consultation notes and post-discharge follow up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) Rehab supervisor did immediate review and training with counselor on filling out required documents and making outreach in a timely manner.
2) Rehab supervisor will do weekly reviews of client records with counselor to identify documents needed and to assist with development of an alert system to assure 100% compliance in the future.
3) The counselor will set reminders in the electronic system to alert the need for follow up outreach to discharged clients. He will document the outcome of the call in call logs.
4) The counselor will complete case consultations notes and follow up phone calls to all clients which have no been completed by 2/22/19.
5) Rehab supervisor will review case load on 2/25/19 to assure that all records are compliant. |