Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a comprehensive treatment plan to include proposed types of supportive services.
The findings include:
The project's policy titled Treatment Management; 60,029; Section C. Comprehensive Treatment Plan (709.92.a), Effective 1/10/11 states:
The Comprehensive Treatment Plan is an individual treatment and rehabilitation plan developed in collaboration with each patient and their assigned Primary Counselor. health services, financial, legal, AA, NA, etc. (709.9.2a.3.).
Six client records were reviewed for comprehensive treatment plan that included support services on March 6, 2013. Two out of six client records lacked documentation of a treatment plan that included a proposed type of support service, specifically client records # 3 and 5.
Client #3 was admitted on November 23, 2012 and was still active at the time of inspection. The comprehensive treatment plan was documented on November 28, 2012; however it did not include a proposed type of support service for client #3.
Client #5 was admitted on September 25, 2012 and was discharged on February 21, 2013. The comprehensive treatment plan was documented on September 25, 2012; however it did not include a proposed type of support service for client #5.
The findings were reviewed with the Director prior to the exit interview.
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Plan of Correction
The Site Director will conduct a staff inservice training for the Paoli location on April 3,2013 on components of the Master Treatment Plan. Site Director will review state guidelines snd facility policies and procedures regarding comprehensive treatment plans that should include proposed types of supportive services. The staff will be educated that The Comprehensive Treatment Plan is an individual treatment and rehabilitation plan developed in collaboration with each patient and their assigned Primary Counselor. health services, financial, legal, AA, NA, etc. (709.9.2a.3.) The Site Director will randomly audit client charts on a monthly basis to ensure that the standard is met. Correective action will be completed by 4-9-2013.
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