Observations
Based on a review of client records on January 4-5, 2018, the facility failed to document an individual treatment and rehabilitation plan that was developed with the client in three of eight client records.Patient #6 was admitted to treatment on January 5, 2017 and is still an active patient. The individualized treatment and rehabilitation plan was developed and signed by staff on January 30, 2017. The treatment plan was not signed by the client until January 31, 2017. Patient #7 was admitted to treatment on July 11, 2017 and is still an active patient. The individual treatment and rehabilitation plan was developed and signed by staff on December 28, 2017. The treatment plan was not signed by the client until December 29, 2017.Patient #8 was admitted to treatment on June 6, 2017 and is still an active patient. The individual treatment and rehabilitation plan was developed and signed by staff on August 3 and August 4, 2017. The treatment plan was not signed by the client until August 7, 2017. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 709.92 (a) requiring the facility to provide an individual treatment and rehabilitation plan be developed with the client. In order to ensure an individual and rehabilitation plan is developed within a timely manner to remain in compliance with this regulation, all staff will be trained on this regulation by 1/31/2018 by Executive Director. The treatment and rehabilitation plan will be entered into the SMART system upon admission. The Individual rehabilitation plan will be developed with patient and signed by patient and counselor on same date within specified time frame. The assigned counselor will monitor the due dates and will place patient a dose hold for completion of treatment plan. This will ensure all signatures and services required are completed on time. The Executive Director, Clinical Supervisor and Lead Counselor will review and monitor all new patients' charts to insure it's completed. |