Observations
Based on a review of client records, the facility failed to document proposed type of support service on the comprehensive treatment plans in seven out of seven records reviewed.
Client #1 was admitted on July 22, 2022 and was still active at the time of the inspection. The treatment plan was dated August 23, 2022.
Client #2 was admitted on December 20, 2022 and was still active at the time of the inspection. The treatment plan was dated January 17, 2023.
Client #3 was admitted on November 14, 2022 and was still active at the time of the inspection. The treatment plan was dated December 21, 2022.
Client #4 was admitted on December 8, 2022 and was still active at the time of the inspection. The treatment plan was dated January 3, 2023.
Client # 5 was admitted on October 20, 2022 and was discharged on January 4, 2023. The treatment plan was dated November 17, 2022.
Client #6 was admitted on November 7, 2022 and was discharged on January 25, 2023. The treatment plan was dated December 5, 2022.
Client #7 was admitted on August 29, 2022 and was discharged on January 19, 2023. The treatment plan was dated September 27, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director contacted our EMR System and added support services in our comprehensive assessment. Facility Director and Clinical Supervisor will train staff on 9/6/23 at our treatment team meeting. Clinical Supervisor will continue to ensure that the support services are being filled out with her weekly chart checks, which occur weekly on Fridays and will also be reviewed in weekly supervision with counselors. |