Observations
Based on a review of 4 client records, with all four being reviewed for support services, the facility failed to document an individual treatment plan to include supportive services in four of four client records.
Findings:
Four client records were reviewed on November 4, 2009. Treatment plans were reviewed in four client records. The facility did not document an individual treatment plan to include supportive services in client records # 1, 2, 3 and 4.
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Plan of Correction
A staff meeting was held on Monday November 23, 2009 during which discussion was held and staff were provided a verbal reminder as the need to include supportive services including the client's engaging in religious, medical, legal, educational, vocational, and/or 12 Step sober support systems on the individualized treatment plan. The Program Supervisor and Program Director will track improvement during monthly chart audits and the Continuous Quality Improvement process. |