Observations
The facility failed to document an individual treatment plan that included the frequency of treatment and rehabilitation services in six of six client records reviewed on November 26, 2019.
The individual treatment plans of the following clients indicated they were receiving individual counseling sessions but no frequency of sessions was documented.
Client # 1 was admitted December 6, 2018.
Client # 3 was admitted August 1, 2019.
Client # 4 was admitted February 25, 2019 and discharged June 5, 2019.
Client # 5 was admitted November 14, 2018 and discharged April 19, 2019.
Client # 6 was admitted March 26, 2019 and discharged May 24, 2019.
Client # 7 was admitted April 30, 2019 and discharged September 4, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project will document frequency of treatment and rehabilitation services in the treatment plan. Any deviation from this frequency will be documented in the Client record.
The Project Director will train Individual Staff on this policy and procedure on 12/3/19.
The Project Director will conduct random chart audits to ensure the frequency of services is being documented on the treatment plan. |