Observations
Based on a review of client records, the facility failed to document treatment plans to include proposed support services in three out of eight client records.
The findings include:
Eight client records were reviewed for comprehensive treatment plans which included proposed support services on May 22, 2014. Three of those client records lacked documentation of a treatment plan that included proposed support services, specifically client records # 1, 7, and 8.
The comprehensive treatment plan for client #1 was documented on October 1, 2013; however it did not include the proposed support services for client #1.
The comprehensive treatment plan for client #7 was documented on October 2, 2013; however it did not include the proposed support services for client #7.
The comprehensive treatment plan for client #8 was documented on January 28, 2014; however it did not include the proposed support services for client #8.
The findings were reviewed and confirmed with the clinical supervisor prior to the exit interview.
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Plan of Correction
Preparation and submission of this Plan of Correction is required by state and federal law. This Plan of Correction does not constitute an admission for purposes of general liability,professional malpractice or any other court proceeding.
The Clinical Director/designee will re-educate staff on the policy and procedures regarding documentation of supportive services on all treatment plans and treatment plan reviews. This will be done at a staff meeting on 6/30/14. Random chart audits will be conducted monthly by the clinical director/designee to ensure compliance. Additional training will be provided as necessary. |