Observations
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plans in four of ten client records.
The findings include:
Ten client records were reviewed on March 23, 2016. All ten client records reviewed required documentation that the provision of services were provided in accordance with those specified in the treatment plans. Services were not documented as stated in the treatment plans in records # 1, 7, 8 and 9.
Client # 1 was admitted on January 5, 2016. An individual treatment plan completed on February 2, 2016 stated the client was to receive 1-2 individual sessions and 1 group session per week. For the weeks of February 7, 14 and 28, 2016 there were no individual sessions documented.
Client # 7 was admitted on September 21, 2015 and discharged on March 1, 2016. An individual treatment plan update completed on December 18, 2015 stated the client was to receive 1-2 individual sessions per week. For the week of February 7, 2016, there were no individual sessions documented.
Client # 8 was admitted on August 27, 2015 and discharged on February 8, 2016. An individual treatment plan update completed on November 20, 2015 stated the client was to receive 2-3 individual sessions and 1 group session per week. For the weeks of November 22, 29, December 12, 13, 20 and 27, 2015 and January 10, 2016, there was one individual documented each week. There were no individuals documented for the week of January 10, 2016.
Client # 9 was admitted on August 3, 2015 and discharged on January 4, 2016. An individual treatment plan update completed on October 15, 2015 stated the client was to receive 1-2 individual sessions and 1 group per week. For the weeks of October 27 and November 4, 2015, there were no group sessions documented. An individual treatment plan update completed on December 18, 2015 stated the client was to receive 1-2 individual sessions and 1 group session per week. For the weeks of December 20 and 27, 2015, there were no individual sessions documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counseling staff will participate in training in documenting services as stated in the treatment plan on or before May 1, 2016. This training will review appropriate frequency and duration of individual and group sessions for the clients served in this clinic. The training will detail how to document client no shows and gaps in treatment. The training will reinforce the importance of consistent sessions. The training will remind counselors that counseling services are to be provided according to the individual treatment and rehabilitation plan.
Individual treatment and rehabilitation plans, records of service and progress notes will be reviewed monthly in order to ensure that the counselors are documenting services as stated in the treatment plan. Reviews of the record will be conducted by the clinical supervisor. All treatment records from May 1, 2016 will be in compliance.
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