Observations
The facility failed to develop an individual treatment and rehabilitation plan that included the proposed type of support services in six of seven client records reviewed on November 28, 2018.
Client records # 1, 2, 3, 4, 5 and 6 were missing documentation of the support services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment and aftercare planning will include the discussion of community resources available to support the client's recovery. These supports may consist of community recovery groups, e.g. Alcoholics Anonymous meetings, shelter & housing services, mental health resources, D/A case management services, family, and religious institutions as pertinent to the individual client. This discussion and these resources will be documented in the client record as part of each individualized treatment plan, update, and aftercare plan. This procedure will be carried out by the counselor. Training for this procedure has been facilitated on December 11, 2018 by the Facility Director. A monthly review of charts by the Director will verify that this procedure has been instituted. Treatment and aftercare plans are compliant beginning December 11, 2018. |