Observations
Based on a review of client records on December 20, 2016, the facility failed to document a comprehensive treatment plan that included support services in records 1, 2, 3, 4, 5, 6, 7 and 9.
Client #1 admitted on August 18, 2016 and discharged on November 28, 2016. The comprehensive treatment plan was completed on September 26, 2016.
Client #2 admitted on August 25, 2016 and discharged on October 03, 2016. The comprehensive treatment plan was completed on August 29, 2016.
Client #3 admitted on May 23, 2016 and discharged on November 29, 2016. The comprehensive treatment plan was completed on June 16, 2016.
Client #4 admitted on April 15, 2016 and discharged on August 26, 2016. The comprehensive treatment plan was completed on April 20, 2016.
Client #5 admitted on August 11, 2016 and discharged on September 19, 2016. The comprehensive treatment plan was completed on August 11, 2016.
Client #6 admitted on October 27, 2016 and still active at the time of the inspection. The comprehensive treatment plan was completed on November 15, 2016.
Client #7 admitted on September 29, 2016 and still active at the time of the inspection. The comprehensive treatment plan was completed on October 10, 2016.
Client #9 admitted on September 6, 2016. The comprehensive treatment plan was completed on December 15, 2016.
The findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Counselors received training on 12/21/16 on documentation which included support services within the comprehensive treatment planning. The Facility Director will complete monthly file audits to ensure both Counselors are including support services within the comprehensive treatment plan.
|