Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five out of eleven client records.The findings include:Fourteen outpatient client records were reviewed on August 20-21, 2013. Eleven client records contained individual treatment and rehabilitation plans which were required to include the type and frequency of treatment and rehabilitation services. The individual treatment and rehabilitation plans contained in client records # 4, 6, 9, 12 and 13 did not include the frequency of treatment and rehabilitation services.Client # 4 was admitted to treatment on February 5, 2013. The individual treatment and rehabilitation plan was developed on March 5, 2013. The frequency of treatment and rehabilitation services was not documented.Client # 6 was admitted to treatment on March 29, 2013. The individual treatment and rehabilitation plan was developed on April 26, 2013. The frequency of treatment and rehabilitation services was not documented.Client # 9 was admitted to treatment on April 3, 2013, and was discharged on July 26, 2013. The individual treatment and rehabilitation plan was developed on May 3, 2013. The frequency of treatment and rehabilitation services was not documented.Client # 12 was admitted to treatment on May 8, 2013. The individual treatment and rehabilitation plan was developed on June 7, 2013. The frequency of treatment and rehabilitation services was not documented.Client # 13 was admitted to treatment on June 14, 2013. The individual treatment and rehabilitation plan was developed on July 12, 2013. The frequency of treatment and rehabilitation services was not documented. The findings were reviewed with the Clinical Supervisor and were not disputed.
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Plan of Correction
Each individual treatment and rehabilitative plan will include the type and frequency of rehabilitation services. All clinical staff will attend training August 27, 2013 on proper treatment plan documentation, including the type and frequency of services. This training will be facilitated by the Facility Director and the Clinical Supervisor. The type and frequency of services will be based on the clinical assessment of each patient's need. Prior to signing each treatment plan, the Clinical Supervisor or Lead Counselor will review that the type and frequency of rehabilitative services are accurately documented. This will be immediate and ongoing. Accurate documentation will also be monitored during monthly peer chart reviews as well as monthly quality record reviews done by the supervisory staff. The Facility Director will be responsible for overall compliance. |