Observations
Based on a review of client records, the facility failed to document a treatment and rehabilitation plan update at least every 60 days in five of eight records.
The findings include:
Nine client records were reviewed on November 13, 2015. Eight clients were in treatment over 60 days and required treatment plan updates. The facility failed to document a treatment and rehabilitation plan update every 60 days in client records # 1, 3,4,5,and 6.
Client #1 was admitted to treatment on May 29, 2015 and discharged on August 20, 2015. A comprehensive treatment plan was documented on June 10, 2015. A treatment plan update was due by August 10, 2015. At the time of the inspection there was no documentation of a treatment plan update.
Client #3 was admitted to treatment on April 4, 2015 and discharged on August 7, 2015. A comprehensive treatment plan was documented on April 30, 2015. A treatment plan update was due by June 30, 2015. At the time of the inspection there was no documentation of a treatment plan update.
Client #4 was admitted to treatment on May 22, 2015 and was still active at the time of the inspection . A comprehensive treatment plan was documented on July 30, 2015. A treatment plan update was due by September 30, 2015. At the time of the inspection there was no documentation of a treatment plan update.
Client #5 was admitted to treatment on July 22, 2015 and was still active at the time of the inspection . A comprehensive treatment plan was documented on July 30, 2015. A treatment plan update was due by September 30, 2015. At the time of the inspection there was no documentation of a treatment plan update.
Client #6 was admitted to treatment on August 17, 2015 and was still active at the time of the inspection . A comprehensive treatment plan was documented on August 28, 2015. A treatment plan update was due by October 28, 2015. At the time of the inspection there was no documentation of a treatment plan update.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall train all counselors on 709.92 regarding treatment plan updates by January 4, 2016. Facility Director shall review documentation for compliance on a monthly basis, beginning January 2016. Counselors will maintain schedule addressing due dates for treatment plan updates, beginning January 2016. Counselors will review files prior to individual treatment to ensure compliance, beginning January 2016. |