Observations
Based on a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client in seven of seven records.
Facility policy and procedure states that a comprehensive treatment plan will be developed with the client within 30 days of admission.
Client #1 was admitted to the outpatient level of care on December 4, 2025, and was discharged January 30, 2026. Client #1 was due to receive a comprehensive treatment plan no later than January 3, 2026, however no comprehensive treatment plan was completed for Client #1.
Client #2 was admitted to the outpatient level of care on January 9, 2026, and was discharged March 25, 2026. Client #2 was due to receive a comprehensive treatment plan no later than February 8, 2026, however no comprehensive treatment plan was completed for Client #2.
Client #3 was admitted to the outpatient level of care on May 4, 2026, and was discharged June 16, 2026. Client #3 was due to receive a comprehensive treatment plan no later than June 3, 2026, however no comprehensive treatment plan was completed for Client #3.
Client #4 was admitted to the outpatient level of care on May 11, 2026, and was discharged June 29, 2026. Client #4 was due to receive a comprehensive treatment plan no later than June 10, 2026, however no comprehensive treatment plan was completed for Client #4.
Client #5 was admitted to the outpatient level of care on March 30, 2026, and was discharged June 4, 2026. Client #5 was due to receive a comprehensive treatment plan no later than April 29, 2026, however no comprehensive treatment plan was completed for Client #5.
Client #6 was admitted to the outpatient level of care on March 25, 2026, and was discharged July 1, 2026. Client #6 was due to receive a comprehensive treatment plan no later than April 24, 2026, however the comprehensive treatment plan for client #6 was not completed until May 5, 2026.
Client #7 was admitted to the outpatient level of care on January 23, 2026, and was discharged April 17, 2026. Client #7 was due to receive a comprehensive treatment plan no later than February 22, 2026, however no comprehensive treatment plan was completed for Client #7.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will be in compliance by 10/25/26. To ensure treatment plan timeliness, the Quality Assurance Team will audit at least 5 charts per month looking for timeliness of treatment plans. Director will also audit charts, and we will review Treatment Plans and the Treatment Plan Policy in our biweekly Clinical Team Meeting. The Quality Assurance Team and the Director are responsible for treatment plans being created on time. Defiency will be corrected by utilizing a Chart Audit Checklist for each client and by adjusting the deadline for Comprehensive Treatment Plan completion since current deadline is not realistic. |