Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in four of seven client records reviewed.
The findings include:
On September 26, 2013, seven client records requiring documentation of the proposed type of support services on the individual treatment and rehabilitation plan were reviewed. The facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in client records # 3, 6, 7 and 8.
Client # 3 was admitted January 28, 2013 and the individual treatment and rehabilitation plan was completed on February 11, 2013. The facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan as of September 26, 2013.
Client # 6 was admitted June 7, 2013 and the individual treatment and rehabilitation plan was completed on June 21, 2013. The facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan as of September 26, 2013.
Client # 7 was admitted June 24, 2013 and the individual treatment and rehabilitation plan was completed on July 9, 2013. The facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan as of September 26, 2013.
Client # 8 was admitted October 26, 2012 and the individual treatment and rehabilitation plan was completed on November 9, 2013. The facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan as of September 26, 2013.
The findings were confirmed during an interview with the facility director on September 26, 2013 at approximately 2:00 P.M.
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Plan of Correction
The counselor failed to document any outside proposed support services on the Master Treatment Plan. The counselor will include any proposed outside support services to the supports already being utilized on future clients' Master Treatment Plans. The Facility Director will ensure compliance with this regulation through supervision, review of the manual and regulations and quality assurance reviews. This regulation is in compliance effective 9/26/2013. |