Observations
Based on a review of client records, the facility post-dated treatment plan updates in two of three client records.
The findings included:
Three client records requiring treatment plan updates were reviewed on August 22, 2014. Per the facility policy, treatment plan review and updates are required to be completed every sixty days. The facility post-dated treatment plan updates for clients #1 and #2.
Client #1 was admitted to treatment on 5/15/14. Both the client and the client's counselor signed and post-dated a treatment plan update for 9/15/14.
Client #2 was admitted to treatment on 5/12/14. Both the client and the client's counselor signed and post-dated a treatment plan update for 9/12/14.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All treatment plan updates shall be reviewed on a weekly basis during staff supervision. Each staff shall review and note the need for corrections. Corrections shall be completed, and submitted by relevant staff and reviewed by the Clinical Supervisor before the end of the session and/or day.
The Clinical Supervisor shall ensure that no paperwork is post dated. |
Observations
Based on the review of the client records, the facility failed to document progress notes for counseling sessions and a record of service in three of three client records.
The findings included:
Three client records were reviewed on August 22, 2014. The facility did not document progress notes for counseling sessions and a record service for August 2014 in client records #1, #2, and #3.
Client #1 was admitted to treatment on 5/15/14. The client attended an individual counseling session on 7/16/14 and group counseling sessions on 7/1/14, 7/2/14, 7/3/14, 7/7/14, 7/8/14, 7/9/14, 7/14/14, 7/15/14, 7/16/14, 7/28/14, 7/29/14, and 7/30/14. There were no progress notes completed for these counseling sessions. Additionally, there was not a record of service for August 2014 on file for client #1.
Client #2 was admitted to treatment on 5/12/14. The client attended an individual counseling session on 7/17/14 and group counseling sessions on 7/1/14, 7/2/14, 7/3/14, 7/7/14, 7/8/14, 7/9/14, 7/14/14, 7/15/14, 7/16/14, 7/28/14, 7/29/14, and 7/30/14. There were no progress notes completed for these counseling sessions. Additionally, there was not a record of service for August 2014 on file for client #2.
Client #3 was admitted to treatment on 6/16/14. The client attended group counseling sessions on 6/23/14, 6/24/14, 6/30/14, 7/1/14, 7/2/14, 7/3/14, 7/7/14, 7/8/14, 7/9/14, 7/14/14, 7/15/14, 7/16/14, 7/28/14, and 7/29/14. There were no progress notes completed for these counseling sessions. Additionally, there was not a record of service for August 2014 on file for client #3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor shall ensure that there will be a daily meeting with staff to review chart records for staff appropriate documentation of progress notes, counseling sessions, and record of service. Corrections shall be completed and submitted to the Supervisor before the end of the session and/or day. |