Observations
Based on a review of client records, the facility failed to complete a preliminary treatment plan as part of the intake procedure in four of nine client records reviewed.
The findings include:
Nine client records requiring documentation of a preliminary treatment plan were reviewed on June 23, 2015. The facility failed to document a preliminary treatment plan as part of the intake procedure in client records #3, 4, 5, and 9.
Client #3 was admitted on 11/5/14 and was discharged on 12/26/14. The facility failed to document a preliminary treatment plan in client record #3.
Client #4 was admitted on 5/29/14 and was discharged on 10/9/14. The facility failed to document a preliminary treatment plan in client record #4.
Client #5 was admitted on 11/16/14 and was discharged on 3/23/15. The facility failed to document a preliminary treatment plan in client record #5.
Client #9 was admitted on 3/23/15 and was still active at the time of inspection. The facility failed to document a preliminary treatment plan in client record #9.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At this point, the policy and procedural manual indicate thepreliminary treatment plans will be completed within the first session. The trend has been the assessment process takes minimally 2 sessions. The procedural manual will be updated to outline that the preliminary treatment plans will be completed within the first 2 sessions with the client.
In addition to updating the manual, the facility will utilize an eternal auditor to review all drug and alcohol charts on a quarterly basis. The facility will utilize a contract staff member specifically for auditing charts/records for compliance. This contracted individual will be added to the facilities listing of staff as a non-clinical staff member. |