Observations
Based on a review of client records, the facility failed to document a treatment plan update in four of four client records.
The findings include:
Ten client records were reviewed on February 27, 2013. Five of the ten client records were in the outpatient drug-free activity. Four of the five client records were required to have a treatment plan update. Per the facility policy, treatment plan updates are required to be completed within 60 days of the comprehensive treatment plan. The facility failed to document a treatment plan update in client records #3, 8, 9 and 10.
Client record #3 - The client was admitted on July 26, 2012. The comprehensive treatment plan was completed on August 9, 2012. A treatment plan update was due by October 9, 2010. The facility failed to document the completion of a treatment plan update as of February 27, 2013.
Client record #8 - The client was admitted on September 26, 2012. The comprehensive treatment plan was completed on November 26, 2012. A new treatment plan was completed January 23, 2013, but a review of the progress of the November 26, 2012 treatment plan goals and objectives was not documented.
Client record #9 - The client was admitted on August 29, 2012. The comprehensive treatment plan was completed on October 3, 2012. The treatment plan update was due by December 3, 2012, and was not completed. A new treatment plan was completed on February 6, 2013.
Client record #10 - The client was admitted on September 19, 2012. The comprehensive treatment plan was completed on October 5, 2012. A treatment plan update was due by December 5, 2012. A new treatment plan was completed December 21, 2012, but a review of the progress of the October 5, 2012 treatment plan goals and objectives was not documented. The treatment plan update was due by February 5, 2013, and was not completed.
The findings were reviewed with the facility director and the clinical supervisor and were not disputed.
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Plan of Correction
The Supervisors will review the requirement to complete the treatment plan update and to include the progress related to goals and objectives with all staff by April 30, 2013. A training will be held for staff as part of the staff meetings and clinical support to provide direct instruction on effectively documenting progress on the treatment plan update. The Clinical Director will be responsible for conducting this training by April 30, 2013 and will include written materials in the training for staff guidance. The Clinical Director will continue to work with administration and the electronic medical record vendor to implement a more comprehensive version of the treatment plan program called treatment plan plus by 12/31/13. As of March 4, 2013, a prompt was added to the treatment plan, directing staff to include progress toward treatment in the update. |