Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the client's individual treatment and rehabilitation plan in six of eight applicable client records reviewed.
Client #1 was admitted November 9, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 12, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #2 was admitted November 14, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 14, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #5 was admitted August 7, 2023 and was discharged on September 7, 2023. The individual treatment and rehabilitation plan was completed on August 12, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #6 was admitted July 19, 2023 and was discharged on August 19, 2023. The individual treatment and rehabilitation plan was completed on July 20, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #7 was admitted October 25, 2023 and was discharged on November 10, 2023. The individual treatment and rehabilitation plan was completed on October 27, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #8 was admitted September 20, 2023 and was discharged on October 19, 2023. The individual treatment and rehabilitation plan was completed on September 20, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
This is a repeat citation from the June 13, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Quality Manager will re-educate staff on the Individual and Rehabilitation Policy by January 15, 2024. A signature page will be developed stating understanding. All employees will be required to sign stating they understand the policy relate to the type and frequency of treatment and rehabilitation services. This re-education will be completed by January 15, 2024.
The treatment plan for active clients with deficiencies will be corrected by January 15,2024
New employees will be educated on this policy during new employee orientation starting January 2024. A review for all staff will occur during the yearly annual mandatory training.
Signature pages will be kept in the employee's file. CEO will ensure compliance by reviewing outcome in the weekly POC meeting. |