Observations
Based on the review of patient records, the facility failed to document that the narcotic treatment physician reviewed patient treatment plans in six of sixteen patient records.
The findings include:
Sixteen patient records were reviewed for the completion of treatment plans and/or treatment plan updates on June 25-26, 2014. The facility failed to include documentation in patient records # 2, 3, 4, 8, 13 and 14 that the narcotic treatment physician reviewed the patient's treatment plans.
Patient # 2 was admitted on November 5, 2013. There was no documentation provided that the narcotic treatment physician reviewed the treatment plans completed on 11/26/13, 3/21/14 and 5/27/14.
Patient # 3 was admitted on December 2, 2013. There was no documentation provided that the narcotic treatment physician reviewed the treatment plans completed on 12/10/13, 4/21/14 and 6/18/14.
Patient # 4 was admitted on May 3, 2014. There was no documentation provided that the narcotic treatment physician reviewed the treatment plans completed on 9/20/13, 11/22/13, 1/27/14, 3/14/14 and 5/16/14.
Patient # 8 was admitted on January 9, 2014. There was no documentation provided that the narcotic treatment physician reviewed the treatment plans completed on 1/27/14, 4/14/14 and 6/2/14.
Patient # 13 was admitted on December 19, 2013 and discharged on February 4, 2014. There was no documentation provided that the narcotic treatment physician reviewed the treatment plan completed on January 9, 2014.
Patient # 14 was admitted on August 19, 2013 and discharged on February 12, 2014. There was no documentation provided that the narcotic treatment physician reviewed the treatment plan completed on August 30, 2014.
The Facility Director and Clinical Supervisor were interviewed on June 26, 2014 and confirmed the findings.
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Plan of Correction
Under the direction of the Project Director or designee, effective 8/1/14, the program director will work with the information system department to ensure all issues related to physician signature on completed treatment plans are identified.
Education and training will be provided to the clinical staff by 8/1/14 regarding checking all completed treatment plans have a signature line for the physician. Effective 8/1/14, supervisory staff will conduct 5 chart audits per therapist per month to monitor completed physician signature on treatment plans.
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