Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in one of twelve client records reviewed.Client #1 was admitted on July 28, 2021 and was still active at the time of inspection. There were release of information forms to another treatment provider, a primary care physician, a funding source, and an emergency contact signed by the witness on July 22, 2021. However, the dated signature of the client was not documented on any of the consent forms. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
All Clinical staff will participate in a review of Chapter 709.28 Confidentiality by 2/15/22.
The facility will correct the deficiency upon the clients next in person contact. Past releases will be dated and initialed. In addition, New releases will be created, signed and dated by client and witness.
All staff will in understand that consent must include dated signature of client or guardian.
Clinical Supervisor is responsible to ensure completion and adherence to regulation. |
Observations
Based on a review of client records, the facility failed to provide treatment plan updates within the regulatory timeframe in six of seven client records reviewed.Client #1 was admitted on July 28, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was completed on August 30, 2021 and the first update was due no later than September 30, 2021. However, the update was completed on December 2, 2021. Additionally, the next update was due no later than January 2, 2022, but the update was not completed at the time of the inspection. Client #2 was admitted on November 15, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was completed on November 30, 2021 and the first update was due no later than December 30, 2021. However, the update was not completed at the time of the inspection. Client #4 was admitted on February 20, 2020 and was discharged on May 28, 2020. The comprehensive treatment plan was completed on March 5, 2020 and the first update was due no later than April 5, 2020. However, the update was not completed prior to discharge.Client #5 was admitted on May 11, 2021 and was discharged on August 25, 2021. The comprehensive treatment plan was completed on May 25, 2021 and the first update was due no later than June 25, 2021. However, the update was not completed prior to discharge.Client #6 was admitted on November 17, 2019 and was discharged on May 30, 2020. The treatment plan update was completed on December 9, 2019 and the first update was due no later than January 9, 2020. However, the update was completed on February 24, 2020. Additionally, the next treatment plan update was due no later than March 24, 2020; however, that update was completed on May 28, 2020.Client #7 was admitted on February 5, 2020 and was discharged on June 11, 2020. The comprehensive treatment plan was completed on February 21, 2020 and the first update was due no later than March 21, 2020. However, the update was not completed prior to discharge,These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.82 was clarified at the audit. It was clear that a plan will be reviewed regardless of whether a client is temporarily in a higher level of care.
on January 6 2022, 709.82 was reviewed with all staff that complete Treatment Plans. If student is in a different level of care on day 30 the plan will be reviewed and documented as such in the daily note.
Clinical Supervisor is responsible for ensuring compliance.
Client #1 A Treatment Plan update was completed on January 10th (Changes was closed 1/7/22 due to weather)
Client #2 A Treatment Plan update was completed on January 10th (Changes was closed 1/7/22 due to weather)
Client #4,5,6and 7 have been discharged.
|