Observations
Based on a review of client records, the facility failed to document a treatment plan update at least every 60 days in three of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a treatment plan update were reviewed during the renewal inspection. The facility failed to document a treatment plan update at least every 60 days in client records # 1, 5 and 10.
Client # 1 was admitted on 4/23/2015 and was still an active client at the time of inspection. The client's last two treatment plans were completed on 12/7/2015 and 10/1/2015.
Client # 5 was admitted on 4/24/2015 and discharged on 9/18/2015. The client's last two treatment plans were completed on 7/15/2015 and 5/12/2015.
Client # 10 was admitted on 8/19/2015 and discharged on 12/7/2015. The client's last two treatment plans were completed on 11/19/2015 and 9/17/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Vice-President of Quality Improvement attended staff meeting on January 11, 2016 and re-trained staff on the importance of updating treatment plans at least every 60 days. Office administration will be responsible for overseeing that therapists are notified when updates are due and for tracking completion of the updates. The Quality Improvement Department will ensure ongoing compliance via chart audits. |