Observations
Based on a review of client records, the facility failed to provide documentation that an individual treatment and rehabilitation plan was developed with a client in one of three records reviewed.
The findings include:
On January 15, 2015, three client records requiring documentation that the individual treatment and rehabilitation plan was developed with the client were reviewed. The facility failed to provide documentation that an individual treatment and rehabilitation plan was developed with the client in client record # 5.
Client # 5 was admitted July 1, 2014 and discharged July 23, 2014. The individual treatment and rehabilitation plan was completed July 1, 2014. However, client record # 5 did not include documentation that the individual treatment and rehabilitation plan was developed with the client as of January 15, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The documentation requirements for partial level of care patients and the need to have the patients sign the treatment care plans as evidence that the care plan was completed with the patient's input and collaboration were reviewed in the clinical staff meeting held on 1/26/2015.
Open and closed charts will continue to be audited with results reported to the Performsance Improvement Committee on a monthly basis. |