Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in seven of nine client records.
The findings include:
Ten client records were reviewed on April 18, 2013. Nine of the ten client records records were required to include the type and frequency of treatment and rehabilitation services. The individual treatment and rehabilitation plans contained in client records #1, #2, #5, #6, #8, #9 and #10 did not include the type and frequency of treatment and rehabilitation services.
Client #1 was admitted to outpatient treatment on 10-10-2012, and discharged on 4-15-2013. The individual treatment and rehabilitation plan was developed on 10-25-2012, but did not include the frequency of treatment services.
Client #2 was admitted to outpatient treatment on 10-24-2012, and discharged on 2-22-2013. The individual treatment and rehabilitation plan was developed on 11-6-2012, but did not include the frequency of treatment services.
Client #5 was admitted to outpatient treatment on 2-4-2013, and discharged on 4-2-2013. The individual treatment and rehabilitation plan was developed on 2-4-2013, and included a range of the frequency of treatment services.
Client #6 was admitted to outpatient treatment on 3-19-2013. The individual treatment and rehabilitation plan was developed on 4-17-2013, but did not include the frequency of treatment services.
Client #8 was admitted to outpatient treatment on 1-14-2013, and was discharged on 3-12-2013. The individual treatment and rehabilitation plan was developed on 1-23-2013, but did not include the frequency of treatment services.
Client #9 was admitted to outpatient treatment on 2-20-2013, and discharged on 4-12-2013. The individual treatment and rehabilitation plan was developed on 3-11-2013, and included a range of the frequency of treatment services.
Client #10 was admitted to outpatient treatment on 1-15-2013, and discharged on 2-28-2013. The individual treatment and rehabilitation plan was developed on 1-15-2013, and included a range of the frequency of treatment services.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
A staff meeting with all clinical staff was held on 4/30/2013 to discuss the listed deficiency. Staff were retrained on the correct way to document the type and frequency of treatment and rehabilitation services in the treatment plan. Clinical Supervisor and Program Director will monitor documentation of type and frequency of services during ongoing chart audits. |