Observations
Based on the review of client records and an interview with the facility director, the facility failed to document treatment plans to include a proposed type of supportive service in four of five records.
The findings include:
On June 16, 2011, treatment plans in five client records were reviewed for proposed types of support services, specifically records # 1, 2, 3, 4 and 5. The facility did not document treatment plans to include a proposed type of support services, as per facility policy, in client records # 1, 2, 3 and 5.
The facility ' s policy titled: STANDARD: 709.92 (a) 1-3 Treatment Plans " states:
"Treatment plans will include any proposed type of support services" .
In client record #1, the treatment plan documented on 6/3/11 did not include a proposed type of support service.
In client record #2, the treatment plan documented on 6/3/11 did not include a proposed type of support service.
In client record #3, the treatment plan documented on 6/6/11 did not include a proposed type of support service.
In client record #5, the treatment plan documented on 12/17/10 did not include a proposed type of support service.
An interview with the facility director on June 16, 2011 confirmed the findings.
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Plan of Correction
The treatment plan form will be modified by the LMCS CQI Specialist by 8/1/2011 to prompt the therapist to describe community supports for consumer and to document on the plan how identified community supports will be used. The treat plan will include a sentence in bold such as "Important:Check All Below That Apply" that directs the therapist to community support check-off boxes(already on the plan), and will include
several lines for therapists to elaborate on areas checked off by the therapist and consumer (for example, NA/AA. Program Director and CQI Specialist will train all staff by 8/1 to investigate community supports as part of the assessment and at the time of the treatment plan update.
In the event that no community supports are identified on the TP, therapists will be directed by the CQI specialist and Program Director to revise the plan w/the client at the next session by adding development of community support as a goal/objective/action step (example:Goal-Enhance interpersonal skills/Objective-Improve comfort level and ability to communicate w/peers in social situations/Action Step-Attend weekly RST outside socialization groups) on the treatment plan. CQI specialist will arrange a staff training in August, 2011 to train and practice this w/clinicians. CQI specialist will include this dimension in routine chart audits to ensure social support is being adequately addressed in treatment. |