Observations
Based on a client record review, the facility failed to develop individual treatment and rehabilitation plans with the client in two of six client records.The findings include:Six client records were reviewed on March 12, 2014, and all were required to have an individual treatment and rehabilitation plans developed with the client. Client records # 3 and #4 failed to include documentation.Client #3 was admitted to outpatient treatment on December 23, 2013, and was discharged on March 3, 2014. An individual treatment and rehabilitation plan was not documented for this client.Client #4 was admitted to outpatient treatment on November 18, 2013, but did not begin receiving services until January 9, 2014. An individual treatment and rehabilitation plan was documented and was signed by the counselor on January 23, 2014, but was not signed by the client.The findings were reviewed with the facility director and the adult clinical services manager and were not disputed.
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Plan of Correction
Monthly random chart audits will be completed by Medical Records staff, Clinical Supervisor and/or D&A program staff with specific intent regarding treatment plan completeness. The result of these audits will be reviewed and discussed at weekly staff meetings to resolve any issues. These monthly charts audits are ongoing and will continue.
Clinical Supervisor will meet with D&A staff weekly and review any alerts that have come up via HNA's Treatment Plan Status Reminder tool. New admits into D&A will be reviewed during these team meetings in relation to treatment interventions and treatment plan completion. Clincial Supervisor has scheduled weekly meeting beginning with the week of 3-17-14.
Clinical Supervisor will meet individually with any staff not followoing treatment plan protocols for supervision and disciplinary action when needed. This will occur effective immediately when indicated. |