Observations
Based on a review of client records, the facility failed to document a complete client record on an individual that included case consultations in two of seven client records reviewed, comprehensive treatment and rehabilitation plan in one of nine client records reviewed, follow-up information in one of three client records reviewed, and verification of work therapy in the comprehensive treatment plan in seven of eight client records reviewed.
The findings include:
On May 5, 2014, nine client records requiring documentation of a complete client record were reviewed. The facility failed to document case consultations in client records # 1 and 2, verification of work therapy in the comprehensive and/or treatment plan updates in client records # 2, 3, 4, 5, 6, 7, and 8, comprehensive treatment and rehabilitation plan in client record # 9, and follow-up information in client record # 10.
Client # 1 was admitted October 21, 2013. The case consultation was due January 31, 2014. However, client record # 1 did not include documentation of a case consultation as of May 5, 2014.
Client # 2 was admitted November 12, 2013. The comprehensive treatment and rehabilitation plan was completed November 18, 2013. The facility failed to document work therapy in the comprehensive treatment plan contained in record # 2, as of May 5, 2014. In addition, a case consultation was completed November 27, 2013. The subsequent case consultation was due on or by March 31, 2014. However, client record # 2 did not include documentation of a subsequent case consultation as of May 5, 2014.
Client # 3 was admitted December 6, 2013. The comprehensive treatment and rehabilitation plan was completed December 12, 2013. The facility failed to document work therapy in the comprehensive treatment plan contained in record # 3, as of May 5, 2014.
Client # 4 was admitted February 21, 2014. The comprehensive treatment and rehabilitation plan was completed March 3, 2014. The facility failed to document work therapy in the comprehensive treatment plan contained in record # 4, as of May 5, 2014.
Client # 5 was admitted December 30, 2014. The comprehensive treatment and rehabilitation plan was completed January 6, 2014. The facility failed to document work therapy in the comprehensive treatment plan contained in record # 5, as of May 5, 2014.
Client # 6 was admitted February 26, 2014. The comprehensive treatment and rehabilitation plan was completed March 7, 2014. The facility failed to document work therapy in the comprehensive treatment plan contained in record # 6, as of May 5, 2014.
Client # 7 was admitted January 16, 2014 and discharged April 16, 2014. The comprehensive treatment and rehabilitation plan was completed January 24, 2014. The facility failed to document work therapy in the comprehensive treatment plan contained in record # 7, as of May 5, 2014.
Client # 8 was admitted January 16, 2014. The comprehensive treatment and rehabilitation plan was completed March 24, 2014. The facility failed to document work therapy in the comprehensive treatment plan contained in record # 8, as of May 5, 2014.
Client # 9 was admitted June 14, 2013 and discharged September 16, 2013. The comprehensive treatment and rehabilitation plan was due July 14, 2013. However, client record # 9 did not include documentation of a comprehensive treatment plan as of May 5, 2014.
Client # 10 was admitted August 27, 2013 and discharged September 16, 2013. The follow-up information was due October 16, 2013. However, client record # 10 did not include documentation of follow-up information as of May 5, 2014.
The findings were confirmed during an interview with the facility director on May 5, 2014 at approximately 3:00 P.M.
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Plan of Correction
The Program Director met with Program Supervisor on 5/5/2014 to discuss the clinical documentation findings. The Program Director & Supervisor met with counselors on 5/6/14 to discuss documentation findings. Program Supervisor will train and monitor clinical staff in weekly Clinical Staff Meeting to ensure that documentation of work therapy, case consultations and follow up on discharge clients are documented and submitted on time. |