Observations
Based on a review of client records, the facility failed to document a treatment plan update at least every 60 days in three of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on February 19, 2016. The facility failed to document a treatment plan update at least every 60 days in client records, #1, 2 and 6.
Client #1 was admitted on November 2, 2015 and was still an active client at the time of inspection. The comprehensive treatment plan was developed on November 16, 2015. The treatment plan update was due to be developed by January 16, 2015. As of the date of the licensing inspection the facility failed to document client #1's treatment plan update.
Client # 2 was admitted on December 3, 2015 and was still an active client at the time of inspection. The comprehensive treatment plan was developed on December 3, 2015. The treatment plan update was due to be developed by February 3, 2016. As of the date of the licensing inspection the facility failed to document client #2's treatment plan update.
Client # 6 was admitted on November 10, 2014 and discharged on October 27, 2015. The last two treatment plan updates for client #6 was dated for May 20, 2015 and September 14, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/22/16 at staff meeting, Clinical Supervisor reviewed with counselors the Treatment Plan Update form and policy which was initially introduced January 4, 2015.
Clinical Supervisor and Quality Assurance Manager to conduct and document monthly audits to ensure Treatment Updates are completed each time a new treatment plan is developed, and or prior to the 60th day for each client. Additionally, all Treatment Plan Updates are reviewed and signed by Clinical Supervisor. |