Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis, including individual counseling at least twice weekly, in four of four client records.
The findings include:
Eleven client records were reviewed on November 18, 2013. Six of the eleven client records were reviewed as partial hospitalization records. Four records were reviewed for documentation of individual counseling sessions at least twice weekly. The facility failed to document individual counseling at least twice weekly in client records # 4, 5, 6 and 10.
Client # 4 was admitted on September 19, 2013. The facility failed to document two individual sessions for the weeks of September 23 and 30, 2013 and October 7, 2013. The facility failed to document a second individual session for the weeks of October 14 and 28, 2013 and November 4 and 11, 2013.
Client # 5 was admitted on September 16, 2013. The facility failed to document two individual sessions for the weeks of September 23, 2013 and October 7, 2013. The facility failed to document a second individual session for the weeks of October 21 and 28, 2013.
Client # 6 was admitted on October 3, 2013. The facility failed to document a second individual session for the weeks of October 14, 2013 and November 4, 2013.
Client # 10 was admitted on May 20, 2013 and discharged on June 28, 2013. The facility failed to document two individual sessions for the weeks of May 20, 2013 and June 10, 2013. The facility failed to document a second individual session for the weeks of May 27, 2013 and June 3, 2013.
The Clinical Supervisor was interviewed on November 18, 2013 and did not dispute the findings.
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Plan of Correction
The Clinical Manager held staff meetings on November 20 and November 25, 2013 and reviewed these findings and the related, specific regulation regarding the providing of two individual counseling sessions per week to partial hospitalization clients.
The clinical Manager will begin to conduct daily progress note monitoring of clients on November 25, 2013 and will ensure that, at least two individual sessions are being scheduled and conducted on every partial hospitalization client. This monitoring will be documented and reported to the Director for a period of 4 months. Further daily monitoring will be determined by the end of March, 2014. |
Observations
Based on the review of client records, the facility failed to review and update the treatment and rehabilitation plans at least every 60 days in two of four client records.
The findings include:
Eleven client records were reviewed on November 18, 2013. Five client records were reviewed as outpatient client records. Four of the client records reviewed required treatment and rehabilitation plan updates. The facility failed to review and update the treatment and rehabilitation plans at least every 60 days in client records # 2 and 3.
Client # 2 was admitted on July 29, 2013 and the treatment and rehabilitation plan was completed on August 12, 2013. The treatment and rehabilitation plan update was due by October 12, 2013. The facility failed to complete the treatment and rehabilitation plan update until November 13, 2013.
Client # 3 was admitted on July 25, 2013 and the treatment and rehabilitation plan was completed on August 6, 2013. The treatment and rehabilitation plan update was due by October 6, 2013. The facility failed to complete the treatment and rehabilitation plan update as of November 18, 2013.
The Clinical Supervisor was interviewed on November 18, 2013 and did not dispute the findings.
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Plan of Correction
The Clinical Manager conducted two staff meetings on November 20 and November 25, 2013 and reviewed these findings and the regulation which specifies that treatment plan reviews are to be conducted within 60 days of the established treatment plan.
The Clinical Manager will develop and maintain a client treatment plan file, from which she will identify all outpatient clients treatment plans that are due to be reviewed/updated one week prior to the due date. In turn, she will ensure that need treatment plan reviews will be conducted prior to the scheduled end date.
The manager will provide a report of completed treatment plan and review dates on all clients to the director on a monthly basis.
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