Observations
Based on a review of client records and interviews with project staff, the facility failed to document a treatment plan update at least every 60 days in three of six records reviewed.
The findings include:
Three client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on 11/19/2015. The facility failed to document a treatment plan update at least every 60 days in client records 3, 5 and 7.
Client #3 was admitted on 05/08/2015, and was still an active client at the time of the inspection. A comprehensive treatment plan was completed on 05/22/2015, with treatment plan updates completed on 07/15/2015, and 09/04/2015. The subsequent treatment plan update for the 09/04/2015, treatment plan update was not completed as of the on-site inspection conducted on 11/19/2015.
Client #5 was admitted on 05/06/2015, and was still an active client at the time of the inspection. A comprehensive treatment plan was completed on 05/22/2015, with treatment plan updates completed on 08/12/2015 and 10/02/2015. The treatment plan update completed on 08/12/2015, was conducted more than 60 days subsequent to the comprehensive treatment plan completed on 05/22/2015.
Client #7 was admitted on 08/20/2015, and was still an active client at the time of the inspection. A comprehensive treatment plan was completed on 09/14/2015. The subsequent treatment plan update was not completed as of the on-site inspection conducted on 11/19/2015.
The findings were reviewed with the facility staff.
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Plan of Correction
Treatment plan updates were completed for both Client #3 and Client #7. During a follow-up internal review, the Director of Quality Improvement found that there had been an administration error in entering dates into this facility's internal tracking system. The Director of Quality Improvement and Facility Director will oversee that the facility's tracking system is corrected and that administrative staff responsible are re-trained.
In an upcoming staff meeting, the Clinical Supervisor will re-educate therapists to ensure that treatment plan updates are completed every 60 days. The Director of Quality Improvement will monitor accuracy of the internal tracking system and complete random chart audits to ensure ongoing compliance.
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