Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document a treatment plan update at least every 60 days.
The findings include:
The facility's policy titled "Treatment Plan Updates" states:
All treatment plans shall be reviewed and updated at least every 60 days.
On January 19, 2012, seven client records were reviewed for documentation of a treatment and rehabilitation plan update. The facility failed to document a treatment and rehabilitation plan update every 60 days as per policy in four of seven client records, specifically # 1, 6, 8, and 10.
Client # 1 was admitted to the program on 10/26/11, and at the time of review was an active client.
The comprehensive treatment plan was not documented in client record # 1 at the time of review on 1/19/12.
Per facility policy all treatment plans shall be reviewed and updated at least every 60 days. The facility failed to document a treatment and rehabilitation plan update at the time of review on 1/19/12.
Client # 6 was admitted to the program on 7/19/11 and the last counseling session was on 11/15/11. Client # 6 was discharged on 12/15/11. The comprehensive treatment plan was documented on 9/14/11.
Per facility policy all treatment plans shall be reviewed and updated at least every 60 days.
The facility failed to document a treatment and rehabilitation plan update at the time of review on 1/19/12.
Client # 8 was admitted to the program on 7/13/11 and the last counseling session was on 9/15/11. Client # 8 was discharged on 10/6/11. The comprehensive treatment plan was documented on 7/27/11.
Per facility policy all treatment plans shall be reviewed and updated at least every 60 days.
The facility failed to document a treatment and rehabilitation plan update at the time of review on 1/19/12.
Client # 10 was admitted to the program on 10/7/11, and at the time of review was an active client. The comprehensive treatment plan was documented on 10/31/11.
Per facility policy all treatment plans shall be reviewed and updated at least every 60 days.
At the time of review on 1/19/12 the facility documented one treatment/rehab update on 1/3/12.
The project director did not dispute the findings.
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Plan of Correction
The project director met with counseling staff on 3/20/2012 to discuss the timely update of treatment plans at least every 60 days.
On 4/13/2012 the project director, the clinical supervisor, and counselor will hold special supervisory training to address the timely treatment plan updates.
The counselor will be responsible for the timely updates of treatment plans. The clinical supervisor will be responsible for making sure these updates are taking place during weekly chart reviews.
The project director is ultimately responsible that the above, updates and quality review, are taking place at weekly case review, reports from the clinical supervisor, and random checks. |