Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in six of seven records.
Client #1 admitted September 18, 2025 and still a current client. A treatment plan was completed on November 7, 2025 and the update was due by January 6, 2026 but not completed until January 19, 2026.
Client #2 admitted May 21, 2025 and discharged November 21, 2025. A treatment plan was completed on September 16, 2025 and the update was due by November 15, 2025 but not completed prior to discharge.
Client #3 admitted July 17, 2025 and discharged December 8, 2025. A treatment plan was completed on September 15, 2025 and the update was due by November 14, 2025 but not completed prior to discharge.
Client #5 admitted May 9, 2025 and discharged July 28, 2025. A treatment plan was completed on May 9, 2025 and the update was due by July 8, 2025 but not completed until July 14, 2025.
Client #6 admitted September 25, 2025 and still a current client. A treatment plan was completed on September 25, 2025 and the update was due by November 24, 2025 but not completed until December 5, 2025. Additionally, another update was due by February 3, 2026 but not completed at the time of the inspection.
Client #7 admitted November 13, 2025 and still a current client. A treatment plan was completed on November 13, 2025 and the update was due by January 12, 2026 but not completed until January 27, 2026.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Department staff will meet on 2/18/2026 and review the deficiencies identified in the on site inspection from DDAP. Department staff will review the policies and procedures that relate to this identified deficiency.
The Project Director will be responsible for generating a caseload report on Mondays to identify treatment plan time frames and deadlines for each staff member. The caseload report will be provided to the clinical staff for updates and review with client. The clinician will be responsible for updating the treatment plan within the identified time frame.
The Project Director will be responsible for ensuring that treatment plans are completed as identified by the end of the business week. Any barriers to these time frames will be clearly documented in a written supervision note that both the clinician and the Project Director have access to.
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