Observations
Based on a review of client records, the facility failed to include the proposed type of support service on the individual treatment and rehabilitation plan in two of five client records.The findings include:Nine client records were reviewed on April 8 - 9, 2013. Five client records were reviewed for individual treatment plans and were required to include support services. The facility failed to document the proposed type of support service in client records # 3 and 4.Client # 3 was admitted into treatment on November 8, 2012. The individual treatment and rehabilitation plan was completed on November 8, 2012. The treatment plan in client record # 3 did not include the proposed type of support services.Client # 4 was admitted into treatment on November 7, 2012. The individual treatment and rehabilitation plan was completed on November 21, 2012. The treatment plan in client record # 4 did not include the proposed type of support services.The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
On 4/17/2013 facility director and clinical supervisor met with treatment staff to discuss deficiency. Clinical supervisor clarified types and examples of "of proposed types of supports services" that must be included on treatment plans. Staff asked questions and verified adequate understanding of examples of "support services." Case manager and clinical supervisor will audit future treatment plans to verify that support services are listed. |