Observations
Based on a review of client records, the facility failed to follow their own written policy and procedures for the management of treatment/rehabilitation services for clients in five of seven records reviewed.
The facility policy and procedure manual stated that the preliminary treatment and rehabilitation plan is to be completed on the same day as the level of care assessment.
Client #1 was admitted on November 9, 2023 and was still active at the time of the inspection. The preliminary treatment and rehabilitation plan was due to be completed no later than November 9, 2023; however, the plan was completed on November 29, 2023.
Client #3 was admitted on December 27, 2023 and was still active at the time of the inspection. The preliminary treatment and rehabilitation plan was due to be completed no later than December 28, 2023; however, the plan was completed on January 10, 2024.
Client #5 was admitted on May 23, 2023 and was discharged on July 4, 2023. The preliminary treatment and rehabilitation plan was due to be completed no later than June 5, 2023; however, the plan was completed on June 7, 2023.
Client #6 was admitted on September 5, 2023 and was discharged on October 19, 2023. The preliminary treatment and rehabilitation plan was due to be completed no later than September 5, 2023; however, the plan was not completed prior to client's discharge.
Client #7 was admitted on October 6, 2023 and was discharged on December 1, 2023. The preliminary treatment and rehabilitation plan was due to be completed no later than October 8, 2023; however, the plan was completed on October 9, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor (CS) and the Executive Director (ED) met for supervision on 2/5/24 to discuss this policy and procedure citation. CS and ED completed the training to correct this action on 2/5/24. CS and ED will return to weekly supervision on 2/12/24 and will be in full compliance with this corrected citation by 3/12/24. The CS and the Quality Management Team will conduct monthly chart audits to ensure this citation does not occur again. The ED will communicate with the CS weekly and the Quality Management Team monthly to maintain audit compliance during the year. |