Observations
Based on a review of client records, and a discussion with the facility director, the facility failed to provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plans, in three client records.
The findings include:
Thirteen client records were reviewed on April 18 and 19, 2011. The individual treatment and rehabilitation plans were required to document proposed type of support services in three client records. The facility did not document proposed type of support services in client records # 7, 10, and 12.
Client # 7 was admitted on February 17, 2011.. The individual treatment and rehabilitation plan was completed on March 18, 2011. There was no documentation of support services in the treatment plan.
Client # 10 was admitted on March 3, 2011. The individual treatment and rehabilitation plan was completed on April 7, 2011. There was no documentation of support services in the treatment plan.
Client # 12 was admitted on February 9, 2011. The individual treatment and rehabilitation plan was completed on March 15, 2011. There was no documentation of support services in the treatment plan.
In a discussion with the facility director and administrative staff at the exit interview it was confirmed that supportive services were not being documented on the comprehensive treatment plans. Although the documentation is on the initial treatment plans supportive services are not carried over to the comprehensive treatment plans. The use of the current treatment planning system, Tower, is going to be discontinued. once that is completed current treatment plans will contain documentation of supportive services.
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Plan of Correction
The facility did not provide written documentation of proposed support services in the individual treatment plan.
It it the responsibility of the facility to document any and all referrals to support services in the treatment plan.
The Facility Director will provide an onsite training on utilizing and identifying supportive services in treatment planning by 6/14/11 to all counseling staff. The Lead Counselor along with the Director will review all treatment plans to ensure compliance with this regulation.
The Facility Director will monitor for ongoing compliance through regular record review. |