Observations
Based on a review of client records, the facility failed to document a treatment and rehabilitation plan review and update at least every 30 days in two of seven client records reviewed.
The findings include:
Seven client records which required documentation of a treatment and rehabilitation plan review and update at least every 30 days were reviewed June 30, 2014. The facility failed to complete a review and update of the treatment and rehabilitation plan at least every 30 days in client records # 5 and 6.
Client # 5 was admitted on 12/31/13 and was discharged on 3/10/14. The comprehensive treatment plan for this client was developed on 1/2/14. An updated was due to be completed by 2/2/14, however, it was not completed until 2/14/14.
Client # 6 was admitted on 1/26/14 and was discharged on 4/24/14. The comprehensive treatment plan for this client was developed on 1/29/14. An updated was due to be completed by 3/1/14, however, it was not completed until 3/14/14.
The Facility Director confirmed the findings.
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Plan of Correction
The Clinical Director is ultimately responsible for the corrective action plan and for overall and ongoing compliance.
Saint John Vianney Center has identified the completion of treatment and rehabilitation plans with all required signatures as an area for improvement. Both of the cases cited were closed charts and improvement has been made in recent months to have all team members sign within 72 hours of the plan date to therefore ensure that the plans are completed in a timely manner and stay on schedule for 30 day reviews.
Every patient will have a treatment and rehabilitation plan written within 72 hours of admission, 10 days of admission and 30 days of admission. This treatment and rehabilitation plan will be reviewed and updated at least every 30 days.
Participants in the initial treatment and rehabilitation plan were identified. The psychiatrist will develop the initial treatment and rehabilitation plan with input from the patient and the nursing assessment at the psychiatric evaluation. The patient and psychiatrist will sign the plan. The psychiatrist will give the plan to the unit nurse for his/her signature and filing in the medical record.
The 10 and 30 Day treatment and rehabilitation plan and the 30 day treatment and rehabilitation plan review and update will be developed by the primary counselor with input from the patient. The plan will be reviewed with the rest of the treatment team at the treatment team meeting with the opportunity for the team to provide input. The treatment plan will be signed by the team members at the treatment team meeting. If a team member is on vacation, the supervisor will sign the treatment plan. The primary counselor is responsible for reviewing the plan with the patient and obtaining the patient's signature. All plans and reviews will be signed within 72 hours.
Clinical staff will be re-educated on the treatment and rehabilitation plan policy as outlined above on 7/21/14.
All treatment and rehabilitation plans and treatment and rehabilitation plan reviews are audited weekly for compliance with this corrective action plan. Findings are reported to the Clinical Director for supervision of the primary counselors and other clinical staff. Compliance is reviewed at the Performance Improvement Committee monthly.
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