Observations
Based on a review of client records, the facility failed to document a treatment plan update in four of eight client records.
The findings include:
Ten client records were reviewed on June 8, 2011. Eight client records were required to have a treatment plan update. Per the facility policy, treatment plan updates are required to be completed within 60 days of the comprehensive treatment plan. The facility failed to document a treatment plan update in client records #2, #4, #9 and #10.
Client record #2 - The client was admitted on December 21, 2010. A preliminary treatment plan was completed on 12-21-10 and again on 2-28-11 due to lack of attendance. The comprehensive treatment plan was completed on March 22, 2011. A treatment plan update was due by May 22, 2011 but was not documented. The facility failed to document the completion of a treatment plan update as of the date of this inspection on June 8, 2011.
Client record #4 - The client was admitted on March 17, 2011. The comprehensive treatment plan was completed on March 31, 2011. A treatment plan update was due by May 31, 2011 but was not documented. The facility failed to document the completion of a treatment plan update as of the date of this inspection on June 8, 2011.
Client record #9 - The client was admitted on February 28, 2011. The comprehensive treatment plan was completed on March 21, 2011. A treatment plan update was due by May 21, 2011 but was not documented. The facility failed to document the completion of a treatment plan update as of the date of this inspection on June 8, 2011.
Client record #10 - The client was admitted on January 11, 2011. The comprehensive treatment plan was completed on March 3, 2011. A treatment plan update was due by May 3, 2011 but was not documented. The facility failed to document the completion of a treatment plan update as of the date of this inspection on June 8, 2011.
The Clinical Supervisor and the QA staff member confirmed that the treatment plan updates were not completed for the client records identified.
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Plan of Correction
Staff has been reminded that treatment updates need to be done timely.
Clinical supervisor reviewed the timelines from initial to comprehensive to updates.
The chart audits will focus in closely on the dates of treatmet updates.
The current notification systemin the EMR is being reviewed to determine if it is the most effecient procedure.
The Compliance/Quality Assurence coordinater will be instituting a procedure to identify treatment plans that are nearing their deadline.
The Clinical Supervisor, Compliance Coordinator and IT person will be responsible to institue all these steps by 8/31/2011. |