Observations
Based on a review of client records and facility policy and procedures on January 26 & 27, 2010 the facility failed to document a treatment plan update in four of seven client records in accordance with the facility policy and procedures.
The findings include:
Seven client records were reviewed on January 26, 2010 and January 27, 2010. All seven records required updates to be completed at least every sixty days per facility policy and procedures. Four out of the seven records had late updates .
Client #1 was admitted on May 13, 09 and the individual treatment plan was completed on May 13, 09. The treatment update was not completed until July 22, 09.
Client #2 was admitted on June 12, 09 and the individual treatment plan was completed on June 12, 09. The treatment update was not completed until August 14, 09.
Client #3 was admitted on July 13, 09 and the individual treatment plan was completed on July 20, 09. The treatment update was not completed until October 5, 09.
Client #5 was admitted on May 5, 09 and the individual treatment plan was completed on May 5, 09. The treatment update was not completed until July 16, 09.
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Plan of Correction
The assigned Clinical Supervisor will meet with the counselors assigned to client #1, client #2, client #3, and client #4 respectively by 2/12/2010 and review licensing standard 709.92(b) which states that treatment and rehabilitation plans must be reviewed and updated every 60 days. At the Clinical Staff Meeting schedule to be held on March 1, 2010, the Director of Clinical Services will review licensing standard 709.92(b) and reinforce that treatment plans must be reviewed and updated every 60 days. Clinical supervisors will continue to consistently monitor the client records of all assigned staff to ensure ongoing compliance with this standard. |