Observations
Based on a review of policy and procedures, client records and staff interviews, the facility failed to document treatment plan updates every 60 days, as per facility policy and regulation, in two of four client records.The findings include:Eight client records were reviewed on May 24 - 25, 2011. Per facility policy and regulation, treatment plan updates will be completed every 60 days. Treatment plan updates were required in four client records. Four client records were not yet due for treatment plan updates. The facility failed to document treatment plan updates every 60 days in client records # 2 and 4.Client # 2 was admitted into treatment on February 9, 2011. The comprehensive treatment plan was completed on February 11, 2011. A treatment plan update was due to be completed no later than April 11, 2011. There was no documentation of a treatment plan update in client record # 2, at the time of the review on May 24 - 25, 2011.Client # 4 was admitted into treatment on December 13, 2010. The comprehensive treatment plan was completed on December 13, 2010. The first treatment plan update was due to be completed no later than February 13, 2011 and was not completed until March 11, 2011. The second treatment plan update was due to be completed no later than May 11, 2011 and was not completed until May 20, 2011.The facility director and clinical supervisor were interviewed on May 25, 2011 and confirmed these treatment plan updates were not completed within the required 60 day time frame.This is a repeat citation.
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Plan of Correction
On July 6, 2011 a mandatory staff meeting will be held to review all treatment plan time lines and regulations. Each staff member will be provided with a copy of our agency policy and regulations in regard to treatment plan timelines. In addition, staff members who were responsible for charts that were missing treatment plan updates will correct these deficiencies no later than July 29, 2011. To assure staff members are improving in this area internal chart audits will be conducted. The Clinical Supervisor and Director shall be responsible for implementing this plan of correction and monitoring same. |