Observations
Based on a review of client records and an interview with the facility director, the facility failed to document an individualized treatment and rehabilitation plan in three of six client records, as required by regulation.
The findings include:
Twelve client records were reviewed on January 7, 2010 and January 25, 2010. Six client records pertained to the partial hospitalization program. Six client records required the completion of individual treatment and rehabilitation plans. Per regulation, the facility is required to complete an individualized treatment and rehabilitation plan with clients. The facility failed to document an individualized treatment and rehabilitation plan in client records # 4, 5 and 6.
Client # 4 was admitted on November 16, 2009. The individual treatment and rehabilitation plan was completed on November 18, 2009. The treatment plan for client # 4 was not individualized. The treatment plan in client record # 4 was identical to client records # 5 and 6. Each treatment plan had identical long and short term goals, objectives, type and frequency of services and support services. The name of the client was the only item that was different on each treatment plan.
Client # 5 was admitted on December 28, 2009. The individual treatment and rehabilitation plan was completed on January 6, 2010. The treatment plan for client # 5 was not individualized. The treatment plan in client record # 5 was identical to client records # 4 and 6. Each treatment plan had identical long and short term goals, objectives, type and frequency of services and support services. The name of the client was the only item that was different on each treatment plan.
Client # 6 was admitted on November 4, 2009. The individual treatment and rehabilitation plan was completed on November 18, 2009. The treatment plan for client # 6 was not individualized. The treatment plan in client record # 6 was identical to client records # 4 and 5. Each treatment plan had identical long and short term goals, objectives, type and frequency of services and support services. The name of the client was the only item that was different on each treatment plan.
The clinical supervisor was interviewed on January 25, 2010 at approximately 11:30 am. The clinical supervisor reviewed each treatment plan and confirmed they were identical. The clinical supervisor confirmed that counselors are required to complete individualized treatment plans to meet the needs of the clients.
|
Plan of Correction
On January 26, 2010, the Clinical Manager reviewed each of the identified treatment plans with the counselor of record. The discussed the need to individualize treatment plans and further discussed examples of how the treatment plans could have been composed differently
On February 1, 2010, in a staff meeting the Clinical Manager discussed and reviewed this issue with all clinical staff.
The Clinical Manager will review the quality of treatment plan composition during the routinely scheduled chart reviews, ensuring individualization of plan development. (Ongoing)
|