Observations
The facility failed to document that treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of eight client records.Ten client records were reviewed on December 7-8, 2016. Eight of the clients reviewed were in treatment long enough to require a treatment plan update. Treatment plans were not reviewed and updated at least every 60 days in client records #3, 4, 9 and 10.Client #3 was admitted on August 16, 2016. The last treatment plan review / update was completed on September 15, 2016. There was no treatment plan review / update completed by November 15, 2016.Client #4 was admitted on June 23, 2016. A treatment plan review / update was completed on August 19, 2016. The next treatment plan review / update was due to be completed by October 19, 2016. The treatment plan review / update was completed on November 16, 2016.Client #9 was admitted on March 24, 2016 and discharged on August 1, 2016. The last treatment plan review / update was completed on May 11, 2016. There was no treatment plan review / update completed by July 11, 2016.Client #10 was admitted on February 29, 2016 and discharged on August 4, 2016. The last treatment plan review / update was completed on May 26, 2016. There was no treatment plan review / update completed by July 26, 2016.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
While our treatment plan goals are injected into our progress notes and progress documented as addressed in the session, we also try to do an updated treatment plan with signatures every 2 months. Some of the records were late in completing this. The plan to correct this issue is two fold:
1) Our compliance Officer will be reviewing the treatment plans for completion every 2 weeks beginning January 6, 2017.
2) Our recent D/A treatment Team meeting on December 14th was used to review the faulty charts and to highlight the need to complete the plans timely, even if the client is not present. This clarified for some the fact that the treatment plan is valid without the clients signature being attached immediately. The Supervisor will continue to highlight this every 3 months during this time. |