Observations
Based on the review of client records, the facility failed to document the type and frequency of services to be offered to each client on each treatment plan.
The findings included:
Eleven client records were reviewed on March 20, 2013. Each record was required to include documentation of the type and frequency of treatment to be offered to each client on the treatment plan. Five of eleven client records failed to include documentation of the type and frequency of service to be offered to the client.
Client record #1 - The client was admitted on October 3, 2012. The master treatment plan was formulated on October 15, 2012. The treatment plan did not indicate group sessions, and was missing the frequency of the individual sessions.
Client record #2 - The client was admitted on November 12, 2012. The treatment plan was formulated on December 10, 2012. The treatment plan did not indicate the frequency of the individual sessions.
Client record #4 - The client was admitted on November 19, 2012. The treatment plan was formulated on December 19, 2012. The treatment plan did not indicate the frequency of the individual sessions.
Client record #6 - The client was admitted on February 21, 2013. The treatment plan was formulated on March 11, 2013. The treatment plan did not indicate the type or frequency of of service to be offered to the client.
Client record #10 - The client was admitted on December 21, 2012 and discharged on February 28, 2013. The treatment plan was formulated on January 4, 2013. The treatment plan did not indicate the frequency of the individual sessions.
The findings were reviewed with the director and were not disputed.
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Plan of Correction
We are aware that treatment plans need to include the type and frequency of services to be offered to each client. We had recently revised our treatment plan format to make them more comprehensive and unfortunately this section was accidentally omitted from the revised plans. The new plans have been revised and distributed. They all have a specific section that specifically addresses the type and frequency of services to be offered. Clinical supervisors will routinely review treatment plans to monitor compliance. In addition, the facility director will pull random samples on a monthly basis for additional review. This change has already been instituted. |