Observations
Based on a review of client records, the facility failed to document a treatment plan update at least every 60 days in eleven of thirteen client records reviewed.
The findings include:
Thirteen client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on October 20, 2015. The facility failed to document a treatment plan update at least every 60 days in client records # 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, and 12.
Client # 1 was admitted into treatment on 3/17/15 and was still active at the time of the inspection. The client's individual treatment and rehabilitation plan was completed on 3/18/15. The first treatment plan update for the client was completed on 5/28/15.
Client # 2 was admitted into treatment on 5/15/15 and was discharged on 10/9/15. The client's individual treatment and rehabilitation plan was completed on 5/15/15. The first treatment plan update for the client was completed on 7/27/15.
Client # 3 was admitted into treatment on 5/22/15 and was still active at the time of the inspection. The client's individual treatment and rehabilitation plan was completed on 5/22/15. The first treatment plan update for the client was completed on 7/27/15.
Client # 4 was admitted into treatment on 2/27/15 and was still active at the time of the inspection. The last two treatment plan updates for the client were completed on 8/3/15 and 10/8/15.
Client # 5 was admitted into treatment on 7/1/15 and was discharged on 10/2/15. The client's individual treatment and rehabilitation plan was completed on 7/1/15. The treatment plan update for the client was completed on 9/16/15.
Client # 6 was admitted into treatment on 3/23/15 and was discharged on 8/20/15. The client's individual treatment and rehabilitation plan was completed on 3/24/15. The first treatment plan update for the client was completed on 5/28/15.
Client # 7 was admitted into treatment on 1/19/15 and was discharged on 7/15/15. The client's individual treatment and rehabilitation plan was completed on 1/19/15. The first treatment plan update for the client was completed on 3/24/15.
Client # 8 was admitted into treatment on 3/17/15 and was discharged on 7/31/15. The client's individual treatment and rehabilitation plan was completed on 3/18/15. The first treatment plan update for the client was completed on 5/28/15.
Client # 10 was admitted into treatment on 1/8/15 and was discharged on 7/27/15. The client's individual treatment and rehabilitation plan was completed on 1/8/15. The first treatment plan updated for the client was completed on 3/24/15.
Client # 11 was admitted into treatment on 1/15/15 and was discharged on 3/30/15. The client's individual treatment and rehabilitation plan was completed on 1/15/15. A treatment plan update was not documented in this client's record.
Client # 12 was admitted into treatment on 1/7/15 and was discharged on 8/3/15. The client's individual treatment and rehabilitation plan was completed on 1/7/15. Treatment plan updates for the client were completed on 3/24/15, 5/21/15, and 7/27/15.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/20/15 the outpatient supervisor met with the outpatient counselor about completing the treatment plan update on or before 60 days from the date of the treatment plan completion. As well as completing an update on or before 60 days from the previous update. The outpatient supervisor sent an email to all outpatient counselors advising them to complete the update on or before 60 days. This was sent 10/20/15. For client #1,2,3,4,5,6,7,8,10,11,12 all the subsequent updates will be done on or before 60 days from the previous treatment plan update.
The Outpatient files will be reviewed monthly by the supervisor and outpatient counselor. At staffing with the medical director, the outpatient supervisor will review the dates of the update to ensure it is within 60 days of the treatment plan completion and all subsequent updates will be done on or before 60 days from the previous update. Peer chart review involving all outpatient counselors and the outpatient supervisor will occur bi-monthly at the department meetings to ensure compliance. In addition a form has been developed by an outpatient counselor and is placed on the face sheet of every client file where we can put the dates we are completing the treatment plan updates. Compliance is expected immediately.
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