Observations
Based on a review of inpatient client records, the facility's policies and procedures, and an interview with the clinical supervisor the facility failed to document treatment plans in accordance with facility policies and procedures in four of seven inpatient client records reviewed.
Findings:
Facility policy (709.53 Client Records: Treatment Care Plan, Dated March 7, 2005) stated:
It is the policy of of WDR/CFBHS to maintain a completed Treatment Care Plan for all individuals served by the program. The Treatment Care Plan will be maintained in the client chart.
The Treatment Care Plan must be completed within 7 days of admission.
Seven inpatient client records requiring treatment plans were reviewed on March 29, 2011. The facility did not document a treatment plan within seven days of admission in inpatient client records # 1, 2, 3, and 5.
Client #1 was admitted on 3/14/2011; the treatment plan was due to be documented by 3/21/2011, the treatment plan had not been documented until 3/28/2011.
Client #2 was admitted on 3/11/2011; the treatment plan was due to be documented by 3/18/2011, the treatment plan had not been documented until 3/25/2011.
Client #3 was admitted on 2/25/2011; the treatment plan was due to be documented by 3/4/2011, the treatment plan had not been documented until 3/18/2011.
Client #5 was admitted on 1/6/2011; the treatment plan was due to be documented by 1/13/2011, the treatment plan had not been documented until 1/14/2011.
On March 30, 2011 an interview was conducted with the clinical supervisor, The Clinical Supervisor confirmed that Treatment Care Plans are due within seven days of admission.
|
Plan of Correction
All treatment plans shall be completed in accordance with facility policy and procedures. The Clinical Director will train all new and current counseling staff on the applicable policy and procedures related to the timely completion of treatment plans and all related clinical documentation. Current staff will be re-trained on April 20th and new staff will be trained as part of the new employee orientation training. The Clinical Director will also routinely audit current client charts on a weekly basis to ensure the charts are complete and timelines are being met in accordance with the facility policy beginning immediately The Clinical Director will also continue to conduct on-going supervision of the counseling staff to further ensure all clinical documentation is being completed as per policy. |