Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of six records reviewed.
Client #1 was admitted on December 3, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 3, 2022 and the next update was due no later than May 3, 2022; however, the next update was completed on July 8, 2022.
Client #4 was admitted on May 9, 2022 and was still active at the time of the inspection. A treatment plan update was completed on July 25, 2022 and the next update was due no later than September 25, 2022; however, it was completed on October 11, 2022.
Client #6 was admitted on March 31, 2022 and discharged on July 19, 202. A treatment plan update was completed on May 31, 2022 and the next update was due no later than July 31, 2022; however, no update was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Manager will facilitate review of DDAP regulations regarding treatment plan procedures in Team meeting. Regulation review will not be limited to treatment plan reviews but also include master and preliminary procedures. Clinical Lead and Program Manager will follow up with therapists individually in Supervision to answer questions. This will be completed at team meeting on 12/22/22 and during supervisions by 1/15/23.
Program manager will review the POWER discharge policy and procedure in team meeting. Program Manager and Clinical Lead will follow up with therapist individually in supervision regarding clients that are not attending treatment regularly to maintain compliance with the discharge process. This will be completed at team meeting on 12/22/22 and during supervisions by 1/15/23.
Program Manager and Clinical lead are working with EMR documentation specialist to create electronic record of Quality and Assurance of therapist charts. Therapist charts will continue to monitored weekly and reviewed in supervision. Improving the monitoring of charts will eliminate missed dates and ensure that the PND Outpatient team will work within the DDAP regulations and standards of timeframes for clinical documentation. This process will be completed by 2/1/23. |