Observations
Based on a review of the client records, the facility failed to provide a physician signature on treatment plans and treatment plan updates in eight of eight client records.
The findings include:
Ten client records were reviewed on March 29, 2016. Eight client records were required to have a physician signature on the treatment plan and treatment plan updates.
Patient #2, #3, #4, #6, #7, #8, #9, and #10 did not have a physician signature documented on the treatment plan or the treatment plan updates.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor, during the staff meeting on 4/5/16, informed the staff and the program physician that MA funded clients need to have their treatment plans and treatment plan update forms reviewed and signed by the program physician. The Clinical Supervisor will identify clients that are funded through MA and work with the program physician to see that treatment plans and treatment plan updates are signed. The clinical Supervisor will review 6 MA client charts monthly for the next 3 months to ensure that new client Treatment Plans are being signed and Treatment Plan Updates are also being signed. |