Observations
The facility failed to document an individual treatment and rehabilitation plan that included the proposed type of support services in seven of seven client records reviewed on February 11-12, 2019.
Client records # 1, 2, 3, 4, 5, 6 and 7 did not document the proposed type of support services on the individual treatment and rehabilitation plan.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director will inform all clinical staff in person that they will need to add support systems on all treatment plans and treatment plan updates.
Our forms will henceforth have a support service section added to all treatment plans and treatment plan updates to ensure all are being added to the plans. The Clinical Director will ensure change to forms of treatment plans and treatment plan updates to include support systems.
The Clinical Director already reviews charts to ensure compliance with regulations and will be adding this to ensure clinical staff are adding support systems to treatment plans and treatment plan updates.
Support systems have already been added to treatment plans and treatment plan updates as of date 3/21/19 by the Clinical Director and all Clinical staff has been informed of changes in person and by email.
Clinical Director has already reviewed current treatment plans and treatment plan updates and staff is in compliance. |