Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project regarding documentation of medication records in three of eight client records reviewed, progress notes in three of ten client records reviewed, individualized treatment and rehabilitation plan in three of ten client records reviewed, case consultations in one of six client records reviewed, and follow-up information in two of four client records reviewed.
The findings include:
On February 19, 2014, eight client records requiring documentation of medication records, ten client records requiring documentation of a progress notes after each significant client contact, and ten client records requiring documentation of an individualized treatment and rehabilitation plan were reviewed. Also, on February 19, 2014, six client records requiring documentation of case consultations and four client records requiring documentation of follow-up information were reviewed. The facility did not document medication records in three of eight records reviewed, specifically, client records # 1, 2, and 3 and did not document a progress note after each significant contact in three of ten records reviewed, specifically, client records # 1, 2, and 6. Also, the facility did not document an individualized treatment and rehabilitation plan in three of ten records reviewed, specifically, client records # 1, 2, and 6 and did not document case consultations in one of six records reviewed, specifically, client record # 3. In addition, the facility did not document follow-up information in two of four records reviewed, specifically, client records # 9 and 10.
Client # 1 was admitted August 5, 2013. The medication records were due August 12, 2013. However, client record # 1 did not include documentation of medication records as of February 19, 2014. In addition, the client orientation, consent to treatment, consent to release information forms, preliminary treatment and rehabilitation plan, which are considered significant client contacts, were completed and signed by the client August 5, 2013. Also, the individual treatment and rehabilitation plan was completed August 14, 2013, the treatment plan update was completed September 12, 2013, and subsequent treatment plan updates were completed October 23, 2013, December 18, 2013, and February 12, 2014, which are also considered significant client contacts, were completed with the client on the dates of completion. However, client record # 1 did not include documentation of progress notes of the significant client contacts that occurred on August 5, 2013, August 14, 2013, September 12, 2013, October 23, 2013, December 18, 2013, and February 12, 2014. Moreover, the individual treatment and rehabilitation plan was not individualized and was nearly identical to the individual treatment and rehabilitation plan in client records # 2 and 6.
Client # 2 was admitted September 12, 2013. The medication records were due September 19, 2013. However, client record # 2 did not include documentation of medication records as of February 19, 2014. In addition, the client orientation, consent to treatment, consent to release information forms, preliminary treatment and rehabilitation plan, which are considered significant client contacts, were completed and signed by the client September 12, 2013. Also, the individual treatment and rehabilitation plan was completed September 19, 2013, the treatment plan update was completed October 17, 2013, and subsequent treatment plan updates were completed December 16, 2013 and February 10, 2014, which are also considered significant client contacts, were completed with the client on the dates of completion. However, client record # 2 did not include documentation of progress notes of the significant client contacts that occurred on September 12, 2013, September 19, 2013, October 17, 2013, December 16, 2013, and February 10, 2014. Moreover, the individual treatment and rehabilitation plan was not individualized and was nearly identical to the individual treatment and rehabilitation plan in client records # 1 and 6.
Client # 3 was admitted September 16, 2013. The medication records were due September 23, 2013 and the case consultation was due December 31, 2013. However, client record # 3 did not include documentation of medication records and a case consultation as of February 19, 2014.
Client # 6 was admitted October 2, 2013. The client orientation, consent to treatment, consent to release information forms, preliminary treatment and rehabilitation plan, and individual treatment and rehabilitation plan, which are considered significant client contacts, were completed and signed by the client October 2, 2013. Also, the treatment plan update was completed November 7, 2013 and the subsequent treatment plan update was completed January 6, 2014. However, client record # 6 did not include documentation of progress notes of the significant client contacts that occurred on October 2, 2013, November 7, 2013, and January 6, 2014. Moreover, the individual treatment and rehabilitation plan was not individualized and was nearly identical to the individual treatment and rehabilitation plan in client records # 1 and 2.
Client # 9 was admitted October 28, 2013 and discharged January 16, 2014. The follow-up information was due January 23, 2014. However, client record # 9 did not include documentation of follow-up information as of February 19, 2014.
Client # 10 was admitted September 9, 2013 and discharged November 21, 2013. The follow-up information was due November 28, 2013. However, client record # 10 did not include documentation of follow-up information as of February 19, 2014.
The findings were confirmed during an interview with the facility director on February 19, 2014 at approximately 3:00 P.M.
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Plan of Correction
Facility Director will conduct a staff training by 4-15-2014. All clinical staff will be educated and trained on documentation of client records including case consultations, individualized treatment plans,medical records and documentation of all medications that clients are taking. Each client will document the medications that they are taking at the time of the intake evaluation. Counselors will ensure that all medications clients are taking is documented. Medication records will be documented by 4-1-14 for Client records #1,2 and 3. Counselors will document a progress note for each significant client in client records #1,2 and 6. Facility Director will be responsible for making sure these records are in compliance with DDAP regulations.Staff will be trained on documentation of all client contacts, development of individualized treatment plans, documentation of case consultations, and post discharge follow up documentation with clients in accordance with DDAP regulations. Facility Director will make sure that counselors amend the individual treatment plans for client records #1,2 and 6 to make the treatment plans individualized to the client. Also, by 4-1-14 facility director will ensure that there is a documented case consultation for client #3 and also document follow-up information for client records #9 and 10. Facility Director will conduct quarterly random chart audits to ensure all of the above changes are made and that documentation for clinical services meet DDAP standards. |