Observations
Based on review of client records during the licensing inspection on April 1- 3, 2008, the group progress notes were weekly summaries of various group sessions, which is contrary to the requirement that weekly summaries of group sessions may only be used for groups with the same topics presented and facilitated by the same counselor. In client records # 2 and 3, the group progress notes were documented with daily data summaries, but were documented with different topics. At the end of the week one weekly summary was documented for for all of the diverse group sessions conducted.
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Plan of Correction
All group notes will now be written in Data, Assessment, Plan format on a daily basis as of todays date. Group notes will be written by the counselor doing the group. The clinical supervisor will verify this change by monthy chart reviews for the next three months. |