Observations
Based on the review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in seven of ten client records reviewed. The findings include:Ten client records were reviewed for counseling services on 2/17/2015. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records # 1, 2, 3, 5, 6, 8 and 9.Client record # 1 contained a treatment plan dated 12/22/2014 that identified the counseling services to be provided as group therapy sessions 3 times per week. The only group therapy sessions scheduled between the weeks of 2/1/2015 - 2/14/2015 for the client were on 2/2/2015, 2/3/2015, 2/9/2015, and 2/11/2015. Client record # 2 contained a treatment plan dated 12/15/2014 that identified the counseling services to be provided as group therapy sessions 4 time per week. The only group therapy sessions scheduled between the week of 1/18/2015 - 1/24/2015 for the client were on 1/19/2015 and 1/20/2015. Client record # 3 contained treatment plans dated 11/12/2014 and 1/12/2015 that identified the counseling services to be provided as group therapy sessions 4 times per week. The only group therapy sessions scheduled between the weeks of 12/7/2014 - 2/7/2015 for the client were on 12/8/2014, 12/10/2014, 12/11/2014, 12/15/2014, 12/17/2014, 12/18/2014, 12/22/2014, 12/23/2014, 12/29/2014, 12/30/2014, 1/5/2015, 1/12/2015, 1/19/2015, 1/26/2015 and 2/2/2015.Client record # 5 contained a treatment plan dated 7/22/2014 that identified the counseling services to be provided as group therapy sessions 4 times per week. The only group therapy sessions scheduled between the weeks of 8/10/2014 - 8/30/2014 for the client were on 8/10/2014, 8/18/2014, 8/19/2014, 8/26/2014, 8/27/2014 and 8/28/2014.Client record # 6 contained a treatment plan dated 6/23/2014 that identified the counseling services to be provided as group therapy sessions 4 times per week. The only group therapy sessions scheduled between the weeks of 8/3/2014 - 8/16/2014 for the client were on 8/4/2014, 8/5/2014, 8/6/2014, 8/11/2014, 8/12/2014 and 8/13/2014.Client record # 8 contained a treatment plan dated 6/3/2014 that identified the counseling services to be provided as group therapy sessions 1 time per week. The only group therapy sessions scheduled between the weeks of 6/8/2014 - 7/5/2014 for the client were on 6/10/2014 and 6/24/2014.Client record # 9 contained a treatment plan dated 9/9/2014 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks of 9/14/2014 - 9/20/2014 and 10/5/2014 - 10/11/2014. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site Director of Exton will conduct an in-service training on treatment and rehabilitation services in the regular staff meeting on 3/18/2015. This training will review regulations regarding the counseling services satisfied verses the counseling services that are outlined on the individuals treatment plan. The training will review the need to begin recording client absences and the reasoning for the missed session on the record of service. The Site Director will begin chart audits one time per month to review the record of service and treatment plans to ensure the clinicians are in compliance with this policy. The Site Director will continue chart audits each month until the clinicians are in compliance with the state regulations. |
Observations
Based on the review of client records, the facility failed to ensure that an aftercare plan was complete in accordance with the facility's aftercare plan policy in two of two client records reviewed.The findings include:Two client records were reviewed for documentation of an aftercare plan on 2/17/2015. The facility failed to document an aftercare plan in accordance with the facility's aftercare plan policy in client records # 6 and 8. The facility's aftercare plan policy indicates that an aftercare plan must be developed with the client and completed within one month prior to discharge. Client # 6 was admitted on 6/23/2014 and discharged on 9/30/2014. The client's aftercare plan was not dated nor was there documentation that the client participated in the development of the aftercare plan. Client # 8 was admitted on 4/7/2014 and discharged on 8/5/2014. There was no documentation that the client participated in the development of the client's aftercare plan dated 8/5/2014. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site Director of Exton will conduct a training on project management services in the regular staff meeting on 3/25/2015. This training will review the new aftercare plan form, which will include a spot for the date of when it was completed with the client and a spot for the client's signature. This will ensure compliance with the facilities aftercare plan policy to show that the aftercare plan was developed with the client and that is was completed within one month prior to their discharge.
The Site Director will begin chart audits for closed charts one time per month to review the aftercare plans. The Site Director will continue chart audits each month until the clinicians are in compliance with the state regulations.
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