Observations
Based on a review of client records, the facility failed to document treatment and rehabilitation plan updates at least every 60 days in four of seven records reviewed.
The findings include:
Seven client records requiring documentation of a treatment plan update were reviewed on November 5, 2014. The facility failed to document a treatment plan update at least every 60 days in client records # 1, 2, 3, and 4.
Client # 1 was admitted July 31, 2014 and was still an active client as of 11/5/14. A treatment plan update was completed August 25, 2014 and the next treatment plan update was due October 25, 2014. However, client record # 1 did not include documentation of an additional treatment plan update as of November 5, 2014.
Client # 2 was admitted March 20, 2014 and was still an active client as of 11/5/14. A treatment plan update was completed August 7, 2014 and the next treatment plan update was due October 6, 2014. However, the next treatment plan update was not completed until October 9, 2014.
Client # 3 was admitted May 21, 2014 and discharged June 21, 2014. A treatment plan was completed April 11, 2014 and a treatment plan update was due June 11, 2014. However, client record # 3 did not include documentation of an additional treatment plan update as of November 5, 2014.
Client # 4 was admitted April 10, 2014 and discharged August 7, 2014. A treatment plan update was completed May 30, 2014 and another treatment plan update was due July 30, 2014. . However, client record # 4 did not include documentation of an additional treatment plan update as of November 5, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #1 and #2 have been dischrged from treatment.
In an effort to avoid this problem in the future, the facility director and counselor will meet before 12/2/14 to establish the following plan:
1) All treatment plans are to be initiated (and possibly completed) two weeks before the 60 day expiration date.
2)The facility director will review a random sample of one-quarter of the counelor's caseload once a month to insure compliance.
3) The facility director will ascertain that treatment plan updates for all clients are on time.
4)This review process will continue indefinitely.
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