Observations
Based on a review of client records, the facility failed to document a treatment plan update, at least every 60 days, that included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in four of seven client records.The findings include:Eleven client records were reviewed on April 22, 2014. Seven client records required treatment plan updates, at least every 60 days, that included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan. The facility failed to document a treatment plan update, at least every 60 days, that included an assessment of the client's progress in relationship to the stated goals in client records # 3, 4, 9 and 11.Client # 3 was admitted into treatment on January 22, 2014. A comprehensive treatment plan was developed with the client on January 22, 2014. A treatment plan update was due to be completed no later than March 22, 2014. The treatment plan update in client record # 3 was not documented until April 1, 2014.Client # 4 was admitted into treatment on October 3, 2013. A comprehensive treatment plan was developed with the client on October 24, 2013. Treatment plan updates were completed on December 24, 2013 and February 24, 2014. These treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan for client # 4.Client # 9 was admitted into treatment on April 30, 2013 and discharged on September 12, 2013. A comprehensive treatment plan was developed with the client on April 30, 2013. The first treatment plan update was due to be completed no later than June 30, 2013 and was not completed until July 22, 2013. The second treatment plan update was due to be completed no later than August 22, 2013 and was completed on August 29, 2013. These treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan for client # 9.Client # 11 was admitted into treatment on July 2, 2013 and discharged on October 16, 2013. A comprehensive treatment plan was developed with the client on July 19, 2013. A treatment plan update was due to be completed no later than September 19, 2013. There were no treatment plan updates documented in client record # 11, as of April 22, 2014.The findings were confirmed by the clinical supervisor on April 22, 2014.
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Plan of Correction
The referenced client records will be corrected. The Clinical Supervisor will review the requirement to complete the treatment plan update and regulatory standards with an emphasis on due dates and time lines. A training will be held for staff as part of the staff meetings and clinical support to provide direct instruction on effectively documenting treatment plan update within the specific due dates. This will be conducted by the Clinical Supervisor and completed by July 31, 2014. Clinical Supervisor will continue to review and treatment plan updates through internal chart reviews and supervision on an ongoing basis. |