Bi-Weekly ILP Report Sample

Review ILP and Client Rights and Client Code of Conduct Violations. Facility Rules Violations. Indicate Plan of action to correct violation/s and identify it in the ILP.

On 8/12/2015, CM met with the client and completed Bi-Weekly ILP Review. Client appeared her stated age and appeared in good health. She was in no acute distress. She was alert, satisfactorily groomed, and casually dressed. She was cooperative and appropriate in the meeting. She had

He reports the patient’s roommate was subsequently evicted from his home after the landlord inquired about the ambulance visiting. He reports he contacted her father concerning the patient residing within the family home, but the father has said no. In addition, he reports he has attempted to contact her uncle but has been unable to make contact with him. He reports he has attempted to make contact with her said friend who is considering allowing her the opportunity to reside with her but she has not answered her phone and he has been unable to leave a voice message. He reports no one wants her in their home, and the patient has “burned her bridges” with family members. He reports her family would benefit from counseling. In addition, he reports her family has high expectations of CPS. He reports her current case was not going to close within 12 days of 06/30/2017. In addition, the case will not

LATE ENTRY On 9/15/2016, CM met with the client for Bi-Weekly ILP Review. Client was dressed appropriately for the weather. She was well groomed. As usual client in the meeting was loquacious, and loud. Client continues to be hostile towards this worker. Client continues to repeat to this worker as quote: "I am not mad with you, and this has nothing to do with you. It's all about DHS and your supervisor." Client was hostile due to an Authorization of Release Form client signed for staff to contact her therapist Dr. Iris Yankelevich for a copy of the client psychosocial and psychiatrist evaluations. Client continues to report that she didn’t signed the Authorization of Release Form because the form stated that the form is for HRA 2010e and she doesn’t know how many time she need to repeat herself that she doesn’t meet the ‘CRITERAI FOR SRO”. CM tries to explain to the client that staff is requesting a copy of her psychosocial and psychiatrist evaluation, but then client continue to talk over CM and threat to contact the Coalition and DHS. Client continues to set in her way and refuses to work with staff to meet her unmet needs. CM observed that the client walk with a book bags and a small shopping cart. Client reported she walk with all her documents and letters from Adult Protective Services & Social Security Administration stating that she is capable of living independently.

CM was out on vacation from 5/3/2017 to 6/14/2017. On 6/20/2017, CM met with the client to complete Bi-Weekly ILP Review. Client was dressed in proper attire for the weather. Her affect and mood was appropriate. Client maintains eyes contact appropriately and she was oriented to person, place, time and situation. Client continue to deny suicidal or homicidal ideation

On 7/11/2015, CM met with the client for Bi-Weekly ILP Review. Client arrived early for the meeting. In the meeting client appears to be well groomed with good hygiene and dressed appropriately for her age. She was calm, cooperative and well related. She discussed typical issues re: her political and

The patient was placed on HOLD to see the writer to address his non-compliance with treatment. The patient was reminded about his Step 3 of the patient engagement. According to the patient as the writer reviewed the patient case history of his no show for counseling, group attendance, and continuously AWOL, the patient only response was, " I, know." The writer then inquired of the patient efforts to engage in mental health services through ICRC. The patient admits that he haven't done the intake when the deadline was extended for the third time. The writer discussed with the patient about the risk of facing an intent to discharge due to his non-compliance and addressed alternatives such as suboxone and transferring to a clinic in Massachusetts to accommodate the work location. The patient declines the writer's suggestion as he wants to remain with HCRC-Hartford due to the positive treatment and said. " You guys really care....I do not want to be discharge.....I, mean what is the process of the intent of discharge?" The writer explained to the patient about the appeal process as his record will be reviewed by the Practice Manager to determine as to whether or not to forward with the discharge or the discharge to be overturn.

CM was out on vacation for the period of 8/15/2015 to 8/24/2015. On 9/1/2015, CM met with the client to complete Bi-Weekly ILP Review. Client arrived early for the meeting. She was alert, satisfactorily groomed, and casually dressed. She was cooperative and appropriate in the meeting. She made eye contact appropriately. The client described her mood as “good” Her affect was in appropriate. She doesn’t appear to be in distress. CM inquires how the client has been doing since the last Bi-Weekly ILP Review. Client replies “ she is good”. She continues to relate she doesn’t make anyone aggravate her. She also mentioned lately one of her male friend graph hole of her cell number, and he calls her every day. CM inquires how it got hold of her cell# client replies “she doesn’t know”. CM advised the client if he continues to harass her two things she can do: One file a police complain or change her cell number.

On 8/7/2015, CM met with the client and completed Bi-Weekly ILP Review. Client arrived early for the meeting; she was alert, satisfactorily groomed, and casually dressed. In the meeting she was cooperative and friendly. CM inquires how client is doing since the last Bi-Weekly ILP Review. Client reported she is exhausted from running around obtaining relevant documents to be submitted to Lemle & Wolfe, Inc. by 8/3/2015. She continues to reports she has Straight Medicaid and she is searching for a Managed Cared that cover oxygen tanks.

The patient went as far to admit that she currently is having a hard time breathing, but has an appointment with her gynecologist on Monday. This writer advised the patient that if she has difficulties breathing she will need to go to the ER immediately and be medically assessed by Nursing. The patient started crying about she does not want to be medically assessed as she needs to return her boyfriend vehicle so that he can work. This writer informed the patient about the seriousness of her health comes first. This writer called Nursing Chrystal, but no response. Then this writer and the patient went to the Nursing Director office to be medically assessed. According to the Nursing Director, she advised the patient to go to the ER first and will not be dosed today unless she provides proof of documentations of her visit. Again, the patient fussed and then says, " I am fine, it's not serious," however, the patient was advised to follow medical

I-CM informed the client that he had contacted and left a message with LA Family Housing the week prior, but no one answered due to the Thanksgiving holiday. CM contacted LA Family Housing again with the client present, but on one answered and a voice message was left. CM continued to assess client’s mental health and medication compliance. CM inquired what outside activities the client has been engaging in. CM inquired about client’s plans for Thanksgiving.

3. What, if any, client rights were violated? Janet was noting down false information on her clients. According to her paperwork she was communicating regularly with her clients but her clients said opposite. It proves that the right of clients of knowing about their treatment was violated and at the same time right of regular communication was also violated. Again the clients weren’t able to get record that Janet maintained on their problem. If they could get the paperwork they would be able to see that Janet were noting down false information on them. Some clients needed referrals but they hadn’t been referred. So they were not getting help which they not only needed.

Late Entry On 6/30/2016, CM met with the client to complete to Bi-Weekly ILP Review. In the meeting, client was dressed appropriately for the weather. She was very loquacious and client. Client appears to have difficulty sustaining attention, client does not seem to listen when spoken to directly and she is unable to follow through on tasks. Client affect is inappropriate and she denied suicidal or homicidal ideation.

CM was out for the period of 5/22/2015 to 6/9/2015. On 6/11/2015, CM met with the client and completed Bi-Weekly ILP Review. Client arrived early for the meeting. She was dressed appropriately for the weather. She appears to be friendly and cooperative. In the meeting the client was very talkative. She mentioned to CM her niece gave birth to a baby girl and she can wait to see the baby. She also mentioned to spoke with her sons last night and everything is well with her family. CM inquires if client participate in the onsite Recreation Activities. Client reported she doesn’t participate in the some of the activities. She prefers to go to Bread of Life for food and socialization.

D-Met with the patient upon request. Upon meeting with the patient, the patient appeared upset and addressed her frustration in this writer's office. According to the patient, she's upset with her PCP forcing the patient to admit herself to the psych. ward to get on medication. Failure to do so, her PCP will complete the medication protection for her electricity. The patient owes over $3000 and with the protection, her light company cannot turn off her lights. Please note, the patient was pacing back and forth and getting emotional. This writer consolet he patient and validated her feelings. According to the patient, she reports that CMHA informed her that she in order to get into their clinic, an evaluation is needed whereas the evaluation can be completed at a hospital; however, the patient is worried about being admitted. Please note, the patient denies any suicidal or homocidal ideation when questioned.