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 five of five applicable client records reviewed.
Client #8 was admitted to the outpatient activity on October 17, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on October 21, 2025; however, there was no written documentation indicating the plan was developed with the client.
Client #9 was admitted to the outpatient activity on June 30, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on June 30, 2025; however, there was no written documentation indicating the plan was developed with the client.
Client #10 was admitted to the outpatient activity on August 18, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on August 18, 2025; however, there was no written documentation indicating the plan was developed with the client.
Client #11 was admitted to the outpatient activity on September 24, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on September 29, 2025; however, there was no written documentation indicating the plan was developed with the client.
Client #12 was admitted to the outpatient activity on August 11, 2025 and was discharged on October 3, 2025. The individual treatment and rehabilitation plan was signed and dated by facility staff on August 18, 2025; however, there was no written documentation indicating the plan was developed with the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director conducted a staff training about the updated treatment plan policy and procedure to all clinical staff members on 2/13/26.
The training focused on the adherence of the documentation of our client's active participation in their treatment plan development in the Outpatient level of care. Effective 2/16/26, the primary therapist will document the client's participation in the development of their master treatment plan in the client's chart in each level of care (e.g. Partial Hospitalization and Outpatient treatment).
The Facility Director will implement a new chart review process starting 2/16/26 and will perform a random monthly audit to ensure compliance with this process in treatment planning. |