Observations
Based on the review of client records and an interview with the clinical supervisor, the facility failed to document signed treatment plan updates every 60 days. The finding includes:Four client records were reviewed during the unannounced plan of correction follow up inspection of November 27, 2012. Three of four records reviewed were required to include documentation of treatment plan updates. Each treatment plan update was to be signed by the counselor and supervisor. Two of three client records had no documentation of treatment plan updates. One client record had a treatment plan update but it was not signed.Client Record # 2- This client was admitted on 7/9/12. A sixty day treatment plan update was documented in the record but did not include signatures of the counselor and clinical supervisor. Client Record # 3- This client was admitted on 8/29/12. There was no documentation of a treatment plan update. Client record # 4 - The client was admitted on 6/19/12. There was no documentation of a treatment plan update. The finding was reviewed with the clinical supervisor and facility director and was not disputed.
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Plan of Correction
A list of all active Alternatives consumers will be reviewed each Monday by Clinical Services Manager and Alternatives staff.
Staff will be expected to determine (from the active consumer listing) what Treatment Plan update forms are due. These forms will be completed that week with follow-up by Clinical Services Manager who will review for accuracy and completeness.
In addition, monthly random chart audits will be completed to ensure that Treatment Plan updates are being complete on time and completely. These chart audits will be reviewed by Clinical Services Manager.
This will be put in place by January 21, 2013. |