Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with the client in four of six records.
Client #1 was admitted to the outpatient level of care on April 22, 2024 and was discharged July 16, 2024. Client #1 had a comprehensive treatment plan dated May 3, 2024, but there was no indication that the treatment plan was developed with the client.
Client #4 was admitted to the outpatient level of care on May 6, 2024 and was discharged July 26, 2024. Client #4 had a comprehensive treatment plan dated June 3, 2024, but there was no indication that the treatment plan was developed with the client.
Client #5 was admitted to the outpatient level of care on April 25, 2024 and was active at the time of review. Client #5 had a comprehensive treatment plan dated June 3, 2024, but there was no indication that the treatment plan was developed with the client.
Client #7 was admitted to the outpatient level of care on May 15, 2024 and was active at the time of review. Client #7 had a comprehensive treatment plan dated May 31, 2024, but there was no indication that the treatment plan was developed with the client.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Program Manager to train program staff on the proper completion of the comprehensive treatment plan including patients participating in the treatment planning session and signing their treatment plan by August 20, 2024.
The Program Manager shall be responsible for verifying accurate completion of the releases by completing random chart supervision in 10% of the charts monthly.
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