HospitalInspections.org

Based on document review and interview, the center failed to ensure the adult representatives of minor patients were informed and approved of the outpatient therapy treatment plan when completed by members of the treatment team for 9 of 10 medical records (MR) reviewed (Patient's #2, 3, 4, 6, 7, 8, 9, 10 & 11).

Findings include:

1. Review of the policy/procedure Care Plan Development (reviewed 3-15) indicated the following: "The patient or legally appropriate guardian/other will participate in the development of the plan and the plan will be mutually agreeable to the patient, physician, and therapist ... The physician receives a copy of the plan for his(her) review and approval ..."

2. Review of the policy/procedure Rehabilitation Services Patient Treatment Plan (reviewed 3-15) indicated the following: "Signature of informed consent will be documented by the patient or legal representative on the treatment plan ..."

3. Review of the physical therapy (PT) and/or occupational therapy (OT) outpatient treatment plans for patient's #2, 3, 4, 6, 7, 8, 9, 10 and 11 lacked documentation indicating the completed treatment plan was reviewed and approved by the adult representative(s) of each minor patient.

4. On 7-11-19 at 1305 hours, staff A5 confirmed the MR for Patient's #2, 3, 4, 6, 7, 8, 9, 10 and 11 lacked documentation indicating the OT and/or PT treatment plans were reviewed and approved by an adult responsible for each minor patient receiving outpatient therapy services.