Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within 30 days of admission established by the facility's policy and procedures manual in three out of seven records reviewed. Client #3 was admitted on November 30, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 30, 2022; however, there was no documentation of it being completed at the time of the inspection.Client #5 was admitted on May 18, 2022 and was discharged on September 7, 2022. A comprehensive treatment plan was due no later than June 18, 2022; however, it was not completed until July 28, 2022.Client #7 was admitted on June 1, 2022 and discharged on October 27, 2022. A comprehensive treatment plan was due no later than July 1, 2022; however, it was not completed until July 8, 2022. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In order to correct this problem, we will provide additional training to our clinical staff in the following manner: A refresher training will be provided by the Clinical Supervisor to all clinical staff members during the 2/21/23 clinical staff meeting. This refresher will emphasize that comprehensive treatment plans are to be done within 30 days of admission and signed within that timeframe by the client. A written overview of the clinical chart progression highlighting timing of treatment plans and updates will be provided to each staff member for their reference and review. A time of questions and answers will be provided in order to clear up any confusion and be sure there is complete understanding by the staff.
Following the training and continuing on an ongoing basis, the Clinical Supervisor will do weekly reviews of the CAM (Client Access Management) dashboard with the clinical staff members during their supervision time. This dashboard alerts each counselor to the date each comprehensive treatment plan, treatment plan update, and case consultation is due. Staff members will be directed to consult the dashboard on a daily basis in order to manage their individual caseload.
Although each counselor is responsible for managing his or her own caseload, the Clinical Supervisor will be responsible for seeing that all staff are trained in the use of the CAM dashboard and in our policies and procedures regarding timely documentation including timely signatures by clients on comprehensive treatment plans. The Clinical Supervisor, Clinical Director, and Project Director as a team are responsible to see that the comprehensive treatment plans are done within 30 days of admission and signed by the client within 30 days as well. |