Observations
Based on a review of client records, the facility failed to document treatment plans to include proposed types of supportive services.
The findings include:
Four client records were reviewed for treatment plans on May 13, 2013. Two out of four client records did not include documentation of a treatment plan that included proposed types of supportive services, specifically client records # 2 and 3.
Client #2 was admitted to treatment on November 16, 2012 and discharged on February 11, 2013. The treatment plan was completed on November 30, 2012; however it did not include a proposed type of support service for client #2.
Client #3 was admitted to treatment on February 11, 2013. The treatment plan was completed on February 25, 2012; however it did not include a proposed type of support service for client #3.
The findings were reviewed with the facility director and clinical supervisor.
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Plan of Correction
A training was held on Tuesday May 14, 2013 to review with all clinical staff the need to have type of support service filled in for every client on each treatment plan. Clinical staff were trained by the Program Supervisor who will also be responsible for ensuring compliance in regard to this deficiency.
To ensure that this does not happen again, the Program Supervisor will be reviewing charts with clinical staff weekly making sure that the paperwork is filled out completely and accurately.
The facility was in full compliance on May 15, 2013.
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