Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in four out of seven client records reviewed.
Client #4 was admitted on March 30, 2022 and discharged on June 1, 2022. A comprehensive treatment plan was developed on March 30, 2022 with no type or frequency identified.
Client #5 was admitted on January 21, 2022 and discharged on May 27, 2022. Updated treatment plans were developed on March 4, 2022 and May 4, 2022 with no type or frequency identified.
Client #6 was admitted on March 8, 2022 and discharged on May 24, 2022. A comprehensive treatment plan was developed on March 22, 2022 with no type or frequency identified.
Client #7 was admitted on March 2, 2022 and discharged on June 22, 2022. A comprehensive treatment plan was developed on March 17, 2022 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation form the September 8, 2021 licensing inspection.
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Plan of Correction
Clinical supervisor will review the client records and ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services. chart audit will be completed as well as education of staff for compliance. Training was on 08/10/2022 |