Observations
Based on the review of client records, the facility failed to document treatment plans to include the type and frequency of services provided.
The findings include:
The facility's policy states:
Each treatment plan should contain a statement of the type and frequency of services provided or arranged for the patient, based upon the patients' unique set of needs.
On February 1-2, 2012 eleven client records requiring treatment plans were reviewed. Six out of eleven treatment plans lacked documentation of the type and frequency of services, specifically client records # 1, 5, 7, 8, 9, and 10.
Client # 1 was admitted on August 10, 2011. The comprehensive treatment plan was documented on September 16, 2011 and did not contain a statement of the type and frequency of services provided.
Client # 5 was admitted on September 19, 2011. The comprehensive treatment plan was documented on October 20, 2011 and did not contain a statement of the type and frequency of services provided.
Client # 7 was admitted on October 29, 2011. The comprehensive treatment plan was documented on November 29, 2011 and did not contain a statement of the type and frequency of services provided.
Client # 8 was admitted on February 17, 2011 and discharged on November 28, 2011. The comprehensive treatment plan was documented on March 15, 2011 and did not contain a statement of the type and frequency of services provided.
Client # 9 was admitted on February 25, 2011 and discharged on December 8, 2011. The comprehensive treatment plan was documented on March 23, 2011 and did not contain a statement of the type and frequency of services provided.
Client # 10 was admitted on January 3, 2011 and discharged on December 6, 2011. The comprehensive treatment plan was documented on October 3, 2011 and did not contain a statement of the type and frequency of services provided.
The findings were confirmed with the facility director during a conversation on February 2, 2012.
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Plan of Correction
All treatment plans are in the process of revision and reformatting to compel clinicians to list each intervention as a stand-alone step with corresponding type of service and frequency of same. Treatment Plan Updates will reflect the same individualized, clinical specificity. All comprehensive treatment plans and updates will be reviewed by the Program Director for compliance during the transition to the newer clinical documentation forms. All clinicians will be trained on the new forms and how to transition from old to new over the next 30 - 60 days.
#1, #5 & #7 have been addessed individually with the clinicians and corrected.
#8, #9, #10 are discharged charts and, as such, cannot be corrected.
All staff have received immediate feedback of the results of the site visit, the area of non-compliance, requirement to be specific when addressing a service related to the goal and the frequency of service delivery as well as indicating the resource/provider of this service.
Person(s) responsible: Primary Counselor, Clinic Director/Clinical Supervisor, Program Director
Timeframe for completion: Immediate to address the non-compliance; 30 - 60 days for transition. Immediate for old forms as they allow this issue to be addressed. |