Observations
Based on the review of client records, the facility failed to review and update the treatment and rehabilitation plan at least every 60 days in three of nine client records.The findings include: Ten client records were reviewed on April 9, 2015. Nine client records required treatment and rehabilitation plan updates at least every 60 days. There was no documentation of a rehabilitation plan update in client records # 6, 7 and 9. Client # 6 was admitted on August 29, 2014 and discharged on December 30, 2014. An individual treatment and rehabilitation plan was completed on September 29, 2014. A treatment plan update was due to be completed by November 29, 2014. There was no documentation of a treatment plan update.Client # 7 was admitted on October 29, 2014 and discharged on February 3, 2015. An individual treatment and rehabilitation plan was completed on November 29, 2014. A treatment plan update was due to be completed by January 29, 2015. There was no documentation of a treatment plan update.Client # 9 was admitted on September 30, 2014 and discharged on March 10, 2015. An individual treatment and rehabilitation plan was completed on October 30, 2014. A treatment plan update was due to be completed by December 30, 2014. There was no documentation of a treatment plan update.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
During a staff meeting on 4/9/2015, the Facility Director reviewed the regulation that treatment plan updates are to be completed at least every 60 days. Administrative Assistants will monitor via the census the need for reviews and alert the clinical staff 14 days prior to the due date that the review is necessary. The Clinical Supervisor will monitor compliance during treatment plan update meetings for the next 6 months. |
Observations
Based on the review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in five of seven client records. The findings include:Ten client records were reviewed on April 9, 2015. Seven client records were reviewed for the assurance that counseling services were provided according to the individual treatment and rehabilitation plan. Counseling services were not provided according to the individual treatment and rehabilitation plan in client records # 2, 5, 6, 9, and 10. Client # 2 was admitted on November 8, 2014. The individual treatment and rehabilitation plan, completed on December 8, 2014 stated that the client was to receive one individual counseling session a month. There were no individual counseling sessions documented for the months of February and March, 2015. Client # 5 was admitted on August 15, 2014 and discharged on December 2, 2014. An individual treatment and rehabilitation plan, completed on September 15, 2014 and a treatment plan update, dated November 15, 2014, stated that the client was to receive one individual counseling session a month. There were no individual counseling sessions documented for the months of September, October and November, 2014. Client # 6 was admitted on August 29, 2014 and discharged on December 30, 2014. An individual treatment and rehabilitation plan, completed on September 29, 2014, stated that the client was to receive one individual counseling session a month. There were no individual counseling sessions documented for the month of October, 2014. Client # 9 was admitted on September 30, 2014 and discharged on March 10, 2015. An individual treatment and rehabilitation plan, completed on October 30, 2014 and a treatment plan update, dated December 30, 2014, stated that the client was to receive one individual counseling session a month. There were no individual counseling sessions documented for the months of November, and December, 2014 and January, 2015. Client # 10 was admitted on September 19, 2014 and discharged on February 17, 2015. An individual treatment and rehabilitation plan, completed on October 19, 2014 and a treatment plan update, dated December 19, 2014, stated that the client was to receive one individual counseling session a month. There were no individual counseling sessions documented for the months of October, November, and December, 2014.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
During a staff meeting on 4/9/2015 the Facility Director instructed clinical staff to indicate the minimum services indicated for each client and that additional services are able to be provided but that treatment plans should indicate realistic frequency of services. The Clinical Supervisor will review treatment plans for compliance that counseling services need to be provided according to the treatment plan as they are being developed ongoing. |