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 #4 was admitted on January 22, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 26, 2021 and the next update was due no later than April 26,2021; however, there was no update documented in the record at the time of the inspection.
Client #5 was admitted on December 29, 2020 and was discharged on April 30, 2021. A treatment plan update was completed on January 22, 2021 and the next update was due no later than February 22, 2021; however, there was no update documented in the record until March 4, 2021.
Client #7 was admitted on November 25, 2020 and was discharged March 20, 2021. A treatment plan update was completed on January 27, 2021 and the next update was due no later than February 27, 2021; however, there was no update documented in the record at the time of the discharge.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
These 3 charts were all on the same counselor's caseload. Treatment plan timeframes were addressed directly with the counselor on 6/1/21, as well as with all of the clinicians in a clinical team meeting also on 6/1/21. The timeframes for treatment plans were reviewed using the clinical workflow document, which all clinicians have a current copy of. The Program Director will monitor chart compliance weekly using our clinical scorecard report, and will conduct bi-weekly clinical chart audits to ensure that Treatment Plans are completed in a timely manner. In addition, the Quality Assurance department will conduct quarterly audits of clinical charts, and the Compliance department will conduct at least annual reviews of all plans of correction to ensure implementation.
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