Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individualized treatment and rehabilitation plan in four of eight client records.
The findings include:
Ten client records were reviewed on August 12, 2015. Eight client records were reviewed for individualized treatment and rehabilitation plans including the type and frequency of treatment and rehabilitation services. The facility failed to document the type and frequency of treatment and rehabilitation services on the individualized treatment and rehabilitation plan in client records # 1, 3, 5 and 6.
Client # 1 was admitted into treatment on May 19, 2015. An individualized treatment plan was developed on June 19, 2015. The facility failed to document the type and frequency of treatment and rehabilitation services on the individualized treatment and rehabilitation plan of client # 1.
Client # 3 was admitted into treatment on April 16, 2015. An individualized treatment plan was developed on May 6, 2015. The facility failed to document the type and frequency of treatment and rehabilitation services on the individualized treatment and rehabilitation plan of client # 3.
Client # 5 was admitted into treatment on March 16, 2015 and discharged on May 18, 2015. An individualized treatment plan was developed on April 13, 2015. The facility failed to document the type and frequency of treatment and rehabilitation services on the individualized treatment and rehabilitation plan of client # 5.
Client # 6 was admitted into treatment on March 6, 2015 and discharged on May 8, 2015. An individualized treatment plan was developed on April 3, 2015. The facility failed to document the type and frequency of treatment and rehabilitation services on the individualized treatment and rehabilitation plan of client # 6.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Assistant Director will have the electronic health record vendor push the type and frequency of treatment and rehabilitation services and the proposed type of support service on the individual treatment and rehabilitation plan from the initial treatment plan to the master treatment plan by 10/31/15 so that the above information is listed as part of the master treatment plan. The residential supervisor will monitor this monthly to ensure that the type and frequency of treatment services and the proposed type of support services are on the master treatment plan. |