Observations
Based on a review of client records, the facility failed to document case consultations every 60 days, at the time of treatment plan updates, according to facility policy in three of three client records.
Client #1 was admitted on November 17, 2020 and is still an active client. There were no case consultations documented in client record #1.
Client #2 was admitted on March 26, 2021 and is still an active client. There were no case consultations documented in client record #2.
Client #6 was admitted on August 24, 2020 and discharged on January 31, 2021. There were no case consultations documented in client record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is policy at this facility for each patient's case to be reviewed in consultation between two qualified staff members at least every 90 days. The review will include changes in assessment if relevant, measures of progress, treatment plan goals, and details of planned interventions. The attestation will be a dated signature by the consulted staff member on the treatment plan (update), in addition to the assigned counselor's signature, and the Medical Review Officer signature in Medicaid cases. This policy is posted in the break room and has been discussed by the director with each counselor. It has gone into effect February 1, 2022 with all new cases and open charts. This POC is under the authority and responsibility of the Facility Director. |