Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan within 30 days of admission, as per facility policy, in eight of fifteen client records.
The findings include:
Fifteen client records were reviewed on February 29, 2012. Individualized treatment and rehabilitation plans were due to be completed within 30 days of admission, as per facility policy, in all fifteen client records. Client records # 1, 2, 8, 9, 10, 13, 14 and 15 did not contain individualized treatment and rehabilitation plans that were completed within 30 days of admission.
Client #1 was admitted on October 14, 2011. The individualized treatment and rehabilitation plan was due to be completed by November 14, 2011. The individualized treatment and rehabilitation plan was completed on November 18, 2011.
Client #2 was admitted on April 12, 2011. The individualized treatment and rehabilitation plan was due to be completed by May 12, 2011. The individualized treatment and rehabilitation plan was completed on May 20, 2011.
Client #8 was admitted on December 9, 2011. The individualized treatment and rehabilitation plan was due to be completed by January 9, 2012. The individualized treatment and rehabilitation plan was completed on February 10, 2012.
Client #9 was admitted on December 21, 2011. The individualized treatment and rehabilitation plan was due to be completed by January 21, 2012. There was no individualized treatment and rehabilitation plan in client record #9.
Client #10 was admitted on January 10, 2012. The individualized treatment and rehabilitation plan was due to be completed by February 10, 2012. There was no individualized treatment and rehabilitation plan in client record #10.
Client #13 was admitted on December 1, 2011. The individualized treatment and rehabilitation plan was due to be completed by January 1, 2012. There was no individualized treatment and rehabilitation plan in client record #13.
Client #14 was admitted on December 14, 2011. The individualized treatment and rehabilitation plan was due to be completed by January 14, 2012. There was no individualized treatment and rehabilitation plan in client record #14.
Client #15 was admitted on January 11, 2012. The individualized treatment and rehabilitation plan was due to be completed by February 11, 2012. There was no individualized treatment and rehabilitation plan in client record #15.
The clinical supervisor was interviewed multiple times on February 29, 2012. The aforementioned information was confirmed.
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Plan of Correction
Program Director or designee shall devise and implement a spread sheet by 4/1/12 that will track all new patients and the services due for each This will specifically include the comprehensive treatment plan due within the 30 days of admission timeframe.
Program Director or designee will complete chart audits of each new patient to assure comprehensive treatment plan is completed within 30 days. A review of the regulation will be completed by Program Director or designee at 3/6/12 clinical staff meeting with all clinical staff.
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