Observations
Based on survey results, patient records, a review of organizational procedures and interviews the hospital failed to review and update treatment plans every seven days.
Findings:
Facility procedures require treatment plan update and review every seven days from the date of the comprehensive treatment plan. An interview with the clinical supervisor and project director on March 2, 2011 verified the treatment plan review and update requirements. Based on a review of patient records on March 3, 2011 the hospital failed to complete treatment plan updates and reviews in four of seven records.
Client record # 1 - Admitted February 19, 2011 with the comprehensive treatment and rehabilitation plan established on February 22, 2011. A treatment plan review was, by facility procedures, required on March 1, 2011. Based on a review of the record on March 3, 2011, the hospital failed to complete the treatment plan update and review within seven days of the comprehensive plan.
Client record # 5 - Admitted December 17, 2010 and discharged December 30, 2010. The comprehensive treatment and rehabilitation plan was established on December 17, 2010. A treatment plan review was, by facility procedures, required on December 24, 2010. Based on a review of the record on March 3, 2011, the hospital failed to complete the treatment plan update and review within seven days of the comprehensive plan.
Client record # 6 - Admitted October 14, 2010 and discharged November 5, 2010. The comprehensive treatment and rehabilitation plan was established on October 15, 2010. A treatment plan review was, by facility procedures, required on October 22, 2010. Based on a review of the record on March 3, 2011, the hospital failed to complete the treatment plan update and review within seven days of the comprehensive plan
Client record # 7 - Admitted January 8, 2011 and discharged January 24, 2011. The comprehensive treatment and rehabilitation plan was established on January 11, 2011. A treatment plan review was, by facility procedures, required on January 18, 2011. Based on a review of the record on March 3, 2011, the hospital failed to complete the treatment plan update and review within seven days of the comprehensive plan.
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Plan of Correction
All program staff will receive training from the Program Director and Clinical Supervisor regarding the requirement for timely treatment planning reviews and updates every seven days of the comprehensive plan, as per policy. All training will be completed by 4/30/11.
The Clinical Supervisor will audit 20 charts per month to monitor the timely completion of treatment plan reviews and updates. Audits will continue until achievement of 100% compliance for two consecutive months. |