Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in four out of seven client records reviewed.
Client #1 was admitted on December 23, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 13, 2022 with no frequency identified.
Client #2 was admitted on August 24, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 15, 2021 with no frequency identified.
Client #3 was admitted on October 27, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 18, 2021 with no frequency identified.
Client #4 was admitted on July 29, 2021 and discharged on January 31, 2022. A comprehensive treatment plan was developed on August 11, 2021 with no frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A clinical staff meeting was held by the Facility Director on 3/30/2022 to discuss the recent DDAP licensing inspection for facility #667070. All staff were made aware of the importance of documenting the frequency of services provided on a client's master treatment plan. Although this information is being documented in progress notes and treatment plan reviews, all staff were informed of DDAP regulation 709.92 requiring this information to appear on the client's master treatment plan.
The Facility Director and Clinical Supervisor will continue to monitor the adherence to this policy during monthly chart audits. All staff were provided any opportunity to have any questions answered and will be reminded of this regulation during future staff meetings.
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