Observations
Based on review of the client records it was determined that the facility failed to document the assessment piece in the individual sessions of the progress notes. In client record # 1, 2, 3, 4, 5, 6, 7 and 8 the individual sessions lacked a clinical assessment of the client's progress in relation to the stated goals and objectives and read as more of a data section recording what the client had said during the session.
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Plan of Correction
We believe that since many of our staff are newer to the field their assessment skills/documentation of assessments are not well developed.
Director and Clinical supervisor(s) have reviewed the skill levels of each staff member using the "Addiction Counseling Competencies" Technical Assistance Publications (TAPs) number 21 developed by SAMSHA/CSAT; identified additional areas of training for each staff member especially in assessment and treatment plan writing.
We have created a "special training plan" for each staff member that will be added to his or her current training plan focusing of assessment and documentation skills.
The director has updated two tools used by clinical supervisors to assess staff member's performance/skills. One is our 30-day needs assessment and the other is our performance review. We have added very specific training need areas so we can better identify staff member education needs.
We plan to assist with the development of staff assessment skills/ documentation in the following manner:
Director has obtained information/study guide from JCAHO in documentation with behavioral health care organizations.
1.Clincial supervisor and director will conduct weekly training sessions for the next 6 weeks that will focus on documentation using exercises from the study guide and information found on CSAT/Samasha website with staff members.
We will keep notes to document any issues as well as any improvement noted.
2. Clinical supervisor, during weekly individual meetings with each staff member will review at least 4 progress notes written by the staff member that week. Clinical supervisor will sign each note that was read. Clinical supervisor and staff member will discuss notes and Clinical Supervisor will give suggestions in improving the notes. Clinical supervisor will keep track of improvement or lack of in the staff members monthly training update summaries.
3. Director will review at least 2 charts of each staff member each month. Director will leave feedback regarding documentation on each chart. Also, director will provide written recommendations for clinical supervisor to follow up with staff members.
4. We will use our current monthly training updates and individual training plans to monitor progress of each staff member.
We will file all information gathered in each members personnel chart.
We plan to complete the 6-week training schedule by December 17, 2007. We will complete a report of this training project.
We have already integrated the progress note reviews in weekly meetings and we will use the competencies checklist for every new hire and at the end of every year when completing new individual training plans.
We plan to insert specific trainings in our 2008 calendar that will address assessment skills and treatment planning.
Director has joined the IRETA program and plans to identify on line courses, (as well as local trainings) that staff can attend/complete focusing on clinical skills.
This training plan will be integrated in our current staff-training plan.
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