Observations
Based on a review of client records, the facility failed to document a treatment plan update within the required time frame in three of eight client records reviewed.
The findings include:
Client #1 was admitted on 6/8/17 and is still an active client. A treatment plan update was completed on 9/28/2017, the following up-date was due to be completed on 11/28/17, but was not completed until 12/4/17.
Client #3 was admitted on 7/18/17 and is still an active client. The comprehensive treatment plan was created on 7/25/17, the following up-date was due to be completed on 9/25/17, but was not completed until 10/24/17.
Client #6 was admitted on 8/3/17 and is still an active client. The comprehensive treatment plan was created on 10/1/2017, the following up-date was due to be completed on 12/1/17, but was not completed until 12/26/17.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Regional Clinical Director and the Facility Clinical Director are responsible for file reviews. The Facility Clinical Director is responsible for reviewing 5 client files per week of each staff she/he supervises. The Regional Clinical Director is responsible for reviewing 2 files for each counselor in each facility per week.
The Facility Clinical Director and the Regional Clinical Director will provide a report to the Director weekly (Monday by noon) detailing the findings in each clinical review.
If the supervisor finds that a treatment plan is more than 24 hours late on more than one occasion they will follow the directions of corrective action plan for counselors. The corrective action plan for counselors are as follows:
1. verbal discussion of the issue which includes a CAP.
2. If the CAP does not prove to be successful and the behavior continues a written warning will be issued along with a CAP.
3. If the CAP still does not prove to be successful the management team will meet with the counselor to determine the issue at hand and create one last CAP.
On 1/5/18 the facility Clinical Director will review with all clinical staff the results of the inspection. She will share with the staff that the CAP developed for this issue includes the file reviews, write ups, and the following
1. All calendars will be updated with the date of the TXU date within the apt.
2. All TXU will be required to be updated every 50 days to allow for weekends, holidays, and additional days within the month.
3. The files that were reviewed in inspection will be reviewed with the staff to help identify the actual problem the counselor experienced in creating the update. The problem then will be discussed to provide alternative solutions. |