Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a comprehensive treatment plan to include proposed types of supportive services.
The findings include:
In reference to treatment plans, the project's policy stated:
The comprehensive treatment plan shall include, but not be limited to, written documentation of a proposed type of support services. Services may include medical, psychiatric or mental health services, financial, legal, AA, NA, etc.
Six client records were reviewed for a comprehensive treatment plan that included support services on March 19, 2013. Three of six client records records lacked documentation of a treatment plan that included a proposed type of support service, specifically client records # 3, 4 and 5.
Client #3 was admitted on October 12, 2012. The comprehensive treatment plan was documented on October 12, 2012; however it did not include a proposed type of support service for client #3.
Client #4 was admitted on June 20, 2012 and discharged on August 15, 2012. The comprehensive treatment plan was documented on June 25, 2012; however it did not include a proposed type of support service for client #4.
Client #5 was admitted on October 2, 2012 and discharged on January 11, 2013. The comprehensive treatment plan was documented on October 4, 2012; however it did not include a proposed type of support service for client #5.
The findings were reviewed with the Facility Director prior to the exit interview.
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Plan of Correction
the site director of Jenkintown will begin training immediately and it will be ongoing. A training will be held on 4/3/13 at Jenkintown for all of the counselors regarding Master Treatment plan, specifically on:
The comprehensive treatment plan shall include, but not be limited to, written documentation of a proposed type of support services. Services may include medical, psychiatric or mental health services, financial, legal, AA, NA, etc. All staff will attend the training and sign off that they understand the intent of this standard. The site dorector will conduct random, monthly chart audits to ensure that the standard has been met. |
Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document an aftercare plan in accordance with the project's policies and procedures.
The findings include:
In reference to aftercare plans the project's policy states:
A Continuing Care Plan is to be completed within one month of the scheduled discharge date....in relation to ongoing individual sessions. To be completed and signed by the counselor and client prior to discharge.
One client record was reviewed for an aftercare plan on March 19, 2013. One out of one client record lacked documentation of an aftercare plan, specifically client record # 4.
Client #4 was admitted on June 20, 2012 and discharged on August 15, 2012. An aftercare plan was due to be documented by August 15, 2012. An aftercare plan was documented in record #4 however it was undated and unsigned by the client. There was no verification that the aftercare plan had been reviewed with client #4.
The findings were confirmed by the Site Director during the exit interview.
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Plan of Correction
The site director of Jenkintown will begin training immediately and it will be ongoing. A staff training will be performed on 4/3/13 for all counselors at the Jenkintown location regarding:
A Continuing Care Plan is to be completed within one month of the scheduled discharge date....in relation to ongoing individual sessions. To be completed and signed by the counselor and client prior to discharge. All counselors at Jenkintown will complete the training and sign off that they understand the standard. The site director of Jenkintown will perform random, monthly chart audits to ensure that the standard has been met.
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