Observations
Based on a review of client records, the facility failed to document a treatment plan update every 30 days in two of five partial hospitalization client records.
The findings include:
Fourteen client records were reviewed on January 9, 2013. Five client records were from the partial hospitalization activity and required documentation of a treatment plan update every 30 days. The facility failed to document the treatment plan updates within the required timeframe in two of five client records, specifically client records # 31 and 36.
Client # 31 was admitted into treatment on 10/22/12 and was an active client at the time of the inspection. The comprehensive treatment plan was completed on 11/2/12. Treatment plan updates were due by 12/2/12 and 1/2/13. The facility failed to document the treatment plan updates for December 2012 and January 2013.
Client # 36 was admitted into treatment on 7/25/12 and was discharged on 9/27/12. The comprehensive treatment plan was completed on 8/3/12. The treatment plan update was due to be completed by 9/3/12. The treatment plan update was not completed until 9/24/12.
The findings were confirmed with the facility director.
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Plan of Correction
All staff received a refresher training on the BDAP guidelines for completing treatment plan updates. All staff were reminded that treatment plan updates for patients in the Partial Hospitalization program are to have updates a minimum of every 30 days. Patients in the Outpatient program are to have treatment plan updates a minimum of every 60 days. The Team Leader is responsible for compliance and will monitor this during monthly chart reviews.
Client 31's chart was updated to adequately reflect the missing Treatment Plan updates.
Completion Date:
Friday, January 18.
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