Observations
Based on a review of client records, the facility failed to document treatment plan updates every 15 days as per facility policy in two of four client records.
Client #4 was admitted on December 20, 2022 and discharged on January 20, 2023. Treatment plans were documented on December 20 & 24, 2022. A treatment plan update was due to be completed by January 8, 2023. There was no treatment plan update documented in client record #4.
Client #9 was admitted on April 10, 2023 and is currently an active client. The first treatment plan was documented on April 11, 2023. A treatment plan update was due to be completed by April 25, 2023. There was no documentation of a treatment plan update in client record #9.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
After reviewing the identified client records the primary counselor failed to update the treatment plan at 15 days per our policy. The facility director will now meet weekly with all counselors individually to ensure documentation is in compliance with this policy. This meeting is in addition to weekly CQI and clinical supervision meetings that also review client records. A new chart audit form has been created that matches our new electronic record system. The facility director is responsible for compliance monitoring for this procedure. |