Observations
Based on a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in three client records reviewed.
Client #1 was admitted on April 21, 2022 and was still active at the time of the inspection. A treatment plan update was completed on May 12, 2022 and the next update was due no later than July 12, 2022; however, there was no update documented in the record at the time of the inspection.
Client #3 was admitted on February 1, 2022 and was still active at the time of the inspection. A treatment plan update was completed on February 15, 2022 and the next update was due no later than April 15, 2021 however, there was no update documented in the record until April 25, 2022.
Client #4 was admitted on June 15, 2022 and was still active at the time of the inspection. A treatment plan update was completed on July 19, 2022 and the next update was due no later than September 19, 2022; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1's counselor was re-trained with the requirements for completing a treatment plan review minimal every 60 days, whether or not the client is present, to ensure the appropriate time frame is met for policy and procedures. The Clinical Supervisor has already completed a review of the treatment plan update requirements, which occurred in the staff meeting on 9/22/2022; the following day of the licensing inspection. There will also be a review quarterly of charts, by the Clinical Supervisor, to ensure all staff are keeping up with requirements. New staff will also receive this training, by the Clinical Supervisor, when hired to ensure there are no gaps in the documentation process.
Client #3's counselor was be re-trained with the requirements for completing a treatment plan review minimal every 60 days, whether or not the client is present, to ensure the appropriate time frame is met for policy and procedures. The Clinical Supervisor has already completed a review of the treatment plan update requirements, which occurred in the staff meeting on 9/22/2022; the following day of the licensing inspection. There will also be a review quarterly of charts, by the Clinical Supervisor, to ensure all staff are keeping up with requirements. New staff will also receive this training, by the Clinical Supervisor, when hired to ensure there are no gaps in the documentation process.
Client #4's counselor was be re-trained with the requirements for completing a treatment plan review minimal every 60 days, whether or not the client is present, to ensure the appropriate time frame is met for policy and procedures. The Clinical Supervisor has already completed a review of the treatment plan update requirements, which occurred in the staff meeting on 9/22/2022; the following day of the licensing inspection. There will also be a review quarterly of charts, by the Clinical Supervisor, to ensure all staff are keeping up with requirements. New staff will also receive this training, by the Clinical Supervisor, when hired to ensure there are no gaps in the documentation process.
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