Observations
The facility failed to document that an individual treatment and rehabilitation plan was developed with the client in three of seven client records reviewed.
Client #4 was admitted on May 31, 2018 and was discharged August 29, 2018.
Client #5 was admitted on October 15, 2018 and was discharged January 30, 2019.
Client #7 was admitted on January 22, 2019 and was discharged March 27, 2019.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Deficiency detected with discharged clients. No active clients noted with this deficiency.
Moving forward, all active clients will have completed treatment plans evidenced by biweekly monitoring of caseloads by clinical supervisor.
Monthly chart audits by clinical supervisor will occur to ensure treatment plans completed.
Additional treatment plan training will occur via biweekly individual supervision 1x/monthly by clinical supervisor to ensure accurate and timely completion of treatment plans.
This training will include reviewing of treatment plan documentation as well as expected treatment plan timelines.
Plan of correction will occur immediately with effective start date of 2/26/2020.
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