Observations
Based on the review of client records, the facility failed to document that work done by the client at the project is an integral part of the treatment and rehabilitation plan.
The findings include:
Seven records were reviewed on June 17, 2013. Verification of work as an integral part of the treatment and rehabilitation plan was required in seven client records. The facility did not document work as an integral part of the treatment and rehabilitation plan in client records.
Client #1,2,3,4,5,6, and 7 failed to have work therapy documented in the comprehensive treatment plan.
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Plan of Correction
"There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to... (709.53)(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan". Counselors will ensure that all assigned chore functions serve a therapeutic purpose, designed to cultivate a specific recovery skill or character quality. Counselors will document work therapy as part of the client comprehensive treatment plan. In addition, general and specific job assignments will be documented on the Job Function Diary Form. The therapeutic purpose or rationale for the assignment shall be documented in the "remarks" section. The Program Director will review regulation 709.53 and the Gaudenzia Policy pertaining to "Therapeutic Chores" in an in-service meeting on July 18, 2013 and will obtain written verification that the policies were reviewed and understood. The Program Director and Clinical Supervisor will ensure compliance through monthly CQI case audits and monthly supervision. |