Observations
Based on a review of residential client records, the facility failed to document proposed type of support service on individual treatment plans in seven out of seven applicable records reviewed.
Client #1 was admitted on April 9, 2024, and was still active at the time of the inspection. The comprehensive treatment plan, completed April 10, 2024, did not document client support services.
Client #2 was admitted on January 26, 2024, and was still active at the time of the inspection. The comprehensive treatment plan, completed February 23, 2024, did not document client support services.
Client #3 was admitted on February 9, 2024, and was still active at the time of the inspection. The comprehensive treatment plan, completed March 7, 2024, did not document client support services.
Client #4 was admitted on October 20, 2023, and was discharged on November 22, 2023. The comprehensive treatment plan, completed October 23, 2023, did not document client support services.
Client #5 was admitted on September 23, 2023, and was discharged on October 3, 2023. The comprehensive treatment plan, completed September 27, 2023, did not document client support services.
Client #6 was admitted on January 4, 2024, and was discharged on January 15, 2024. The comprehensive treatment plan, completed January 4, 2024, did not document client support services.
Client #7 was admitted on January 22, 2024, and was discharged on February 11, 2024. The comprehensive treatment plan, completed January 24, 2024, did not document client support services.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On April 26th, 2024 the Clinical Director emailed our Electronic Medical Record Provider to add the support service box to the treatment plans i.e. master treatment plan and 30,60,90 day updates. A support service box was added, "identified supports contacted" to the treatment plan on May 1st, 2024. The Clinical Director will audit this process weekly. |