Observations
The facility failed to document treatment plan updates at least every 60 days in three of six client records reviewed on November 27 - 28, 2018.Client # 1 was admitted March 7, 2018. The individual treatment plan was completed April 5, 2018. Treatment plan updates were not documented until June 21, 2018 and October 4, 2018.Client # 5 was admitted January 24, 2018 and discharged September 17, 2018. The individual treatment plan was completed January 31, 2018. The only treatment plan update was not documented until June 25, 2018.Client # 7 was admitted April 9, 2018 and discharged September 17, 2018. The individual treatment plan was completed April 23, 2018. No treatment plan updates were documented.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the 2017 licensing inspection.
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Plan of Correction
This citation was a result of some of our counselors still not utilizing our electronic medical records software, as described in last year's plan of correction, to its full potential, and failing to follow through in a timely manner with clients who have begun attending sporadically or have dropped out of treatment.
In order to correct this problem we plan to provide additional training to our clinical staff in the following manner: A refresher training will be provided by the Clinical Supervisor to all our clinical staff members during the 2/1/19 clinical staff meeting. This refresher will emphasize that treatment plan updates are to be done every 60 days even if the client is not attending treatment. A written overview of the clinical chart progression highlighting timing of treatment plans and updates will be provided to each staff member for their reference and review. A time of questions and answers will be provided in order to clear up any confusion and be sure there is complete understanding by the staff.
Following this training and continuing on an ongoing basis, the Clinical Supervisor will do weekly reviews of the CAM (Client Access Management) Dashboard with the clinical staff members during their supervision time. This Dashboard alerts each counselor to the date of the last treatment plan update and to the due date of the next update for each client on his or her caseload. Updates that are due in the next few days appear highlighted in yellow, and those overdue are highlighted in red. This dashboard can be sorted by due date, so that it is possible to see what is due each day as the counselor works. Staff members will be directed to consult this Dashboard on a daily basis in order to manage their individual caseload. For those clients who have not been keeping their appointments, follow-up telephone calls will be made in an attempt to re-engage the clients. Clients who do not respond to our attempts to re-engage will be discharged from treatment per our policies and procedures.
Although each counselor is responsible for managing his or her own caseload and are responsible for making sure each client is contacted and re-engaged in treatment if possible, the Clinical Supervisor will be responsible for seeing that all staff are trained in the use of the CAM Dashboard and in our policies and procedure regarding discharging inactive clients. The Clinical Supervisor, Assistant Administrator and Director as a team are responsible to see that treatment plans and updates are done timely, and clients who have not been attending are discharged from treatment.
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