Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of six applicable records reviewed.
Client #3 was admitted on October 17, 2024, and was still active at the time of the inspection. A treatment plan was completed on October 30, 2024, and the next update was due no later than December 30, 2024; however, there were no further updates documented.
Client #4 was admitted on October 25, 2024, and discharged on February 18, 2025. A treatment plan was completed on October 30, 2024, and the next update was due no later than December 30, 2024; however, there were no further updates documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Identified Deficiency:
The facility failed to update treatment plans within the required 60-day timeframe for Clients #3 and #4.
2. Corrective Actions:
- Immediate Correction:
o Client #3: Treatment plan update has been updated immediately following licensing inspection and will be reviewed every 60 days.
- Staff Training:
All clinical staff will receive training on the 60-day review requirement, proper documentation, and system usage by 3/19/25
- Record Review:
A review of all client records will be completed by the Clinical Supervisor to ensure compliance.
3. Systemic Changes:
- Tracking System:
A new tracking system will be implemented by 3/21/25 to ensure accuracy of treatment plan reviews being completed every 60 days
- Supervisor Review:
The clinical supervisor will conduct bi-weekly reviews of treatment plans, starting 3/21/25
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4. Monitoring & Compliance:
- Bi-weekly treatment plan reviews by the supervisor will ensure ongoing compliance.
- Internal audits will be conducted every 30 days.
5. Responsible Parties:
- Clinical Staff
- Clinical Supervisor
- Facility Director
6. Conclusion:
The facility is committed to ensuring timely treatment plan updates and compliance with 709.92(b). Corrective actions are in place to prevent recurrence.
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