HospitalInspections.org

Based on observation and interview it was determined that the facility failed to follow their own policies and procedures as 1 of 1 patients did not have evidence of "individual therapy" with their "assigned therapist."

Findings were:

Facility policy entitled "Documentation of Family/Individual therapy Notes," reviewed on 2/21/12, stated "The Clinical Services Department will follow the established parameters for documentation of therapy notes including completion within the allotted time frames ...The Social Services Department assigns a therapist for the prescribed therapy ordered ...The assigned therapist contacts the family within 72 hours to schedule family therapy ...The assigned therapist conducts individual therapy within two (2) days of admission."

Review of patient #1's medical record on 2/21/12 revealed that she had family therapy with her "assigned therapist" (staff #4 , Licensed Maters Social Worker) however she did not have individual therapy with her "assigned therapist" during her admission from 9/12/11 to 9/17/11.

During an interview with staff #3 (Director of Social Services) on 2/21/12 she confirmed that staff #4 was patient #1's "assigned therapist", and she confirmed that there was no evidence in patient #1's record indicating that staff #4 conducted an individual therapy session with patient #1 during her admission from 9/12/11 to 9/17/11.