Observations
Based on a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in ten of fourteen records reviewed.
After review, the facility policy and procedure manual stated that the preliminary treatment plan is to be completed within 72 hours of admission.
Client # 10 was admitted to the outpatient activity on December 6, 2023 and was still active at the time of the inspection. The preliminary treatment plan was due to be completed no later than December 9, 2023; however, the plan was completed on December 13, 2023.
Client # 12 was admitted to the outpatient activity on September 11, 2023 and was discharged on December 16, 2023. The preliminary treatment plan was due to be completed no later than September 14, 2023; however, the plan was completed on October 30, 2023.
Client # 13 was admitted to the outpatient activity on August 7, 2023 and was discharged on January 2, 2024. The preliminary treatment plan was due to be completed no later than August 10, 2023; however, the plan was completed on August 25, 2023.
Additionally, the facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within 7 days of admission.
Client # 1 was admitted to the partial hospitalization activity on October 13, 2023 and was still active at the time of the inspection. The individual treatment plan was due to be completed no later than October 20, 2023; however, the plan was completed on December 12, 2023.
Client # 2 was admitted to the partial hospitalization activity on October 23, 2023 and was still active at the time of the inspection. The individual treatment plan was due to be completed no later than October 30, 2023; however, the plan was completed on December 13, 2023.
Client # 7 was admitted to the partial hospitalization activity on May 10, 2023 and was discharged on June 12, 2023. The individual treatment plan was due to be completed no later than May 17, 2023; however, the plan was completed on June 12, 2023.
Client # 8 was admitted to the outpatient activity on August 20, 2023 and was still active at the time of the inspection. The individual treatment plan was due to be completed no later than August 27, 2023; however, the plan was completed on December 21, 2023.
Client # 9 was admitted to the outpatient activity on November 12, 2023 and was still active at the time of the inspection. The individual treatment plan was due to be completed no later than November 19, 2023; however, the plan was completed on December 14, 2023.
Client # 11 was admitted to the outpatient activity on June 12, 2023 and was discharged on August 30, 2023. The individual treatment plan was due to be completed no later than September 6, 2023; however, the plan was completed on September 12, 2023.
Client # 13 was admitted to the outpatient activity on August 7, 2023 and was discharged on January 2, 2024. The individual treatment plan was due to be completed no later than August 14, 2023; however, the plan was completed on August 29, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinicians are responsible for ensuring that all documentation in their assigned caseload are completed timely, which include preliminary treatment plans and individual treatment and rehabilitation plans. The QA Liaison is responsible for ongoing auditing of the charts and each week sends out an email to each clinician with outstanding items. The Facility Director is responsible for ensuring the team follows through on these audits. The team was notified of the findings from this survey and reiterated the importance of timely documentation to prevent this in the future and to utilize the QA Liaison audits on a regular basis to assist with time management. |
Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of fourteen client records reviewed.
Client # 3 was admitted to the partial hospitalization activity on December 12, 2023 and was still active at the time of the inspection. There was documentation of a family session with the client and their adult children on January 5, 2024; however, there were no family members consent to release information forms signed by the client documented in the record prior to the session/disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff was under the assumption that no consent to release needed to be signed since they had received client's verbal consent and willingness to participate in a family session as all that was being released came from the client.
The Compliance Director discussed this with the team that any time therapy is being provided, a verbal consent does not meet the requirements in this treatment setting.
Client #3 now has consents to release signed in their record for their adult children, and the Facility Director is responsible for ensuring that prior to facilitating any family therapeutic session, consent to release is to be signed. |