Observations
The facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of ten client records reviewed on August 7-8, 2017.
Ten records were reviewed. All required treatment plan updates. Updates were late or missing in client records # 3, 4 and 7.
Client # 3 required an update to be completed by May 30, 2017. There was no documentation provided that an update had been completed by May 30, 2017. An update was completed on July 24, 2017.
Client # 4 required updates to be completed by December 26, 2016 and February 26, 2017. There was no documentation provided that the updates had been completed. An update was completed on March 21, 2017.
Client # 7 required an update to be completed by February 16, 2017. There was no documentation provided that an update had been completed by February 16, 2017. An update was completed on March 22, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Under the direction of the Facility Director or designee:
A. All treatment plans will be reviewed and updated every 60 days.
B. Re-education of staff will occur by 9/1/17 re: requirements for tx plans
C. Clinical Supervisors will perform monthly chart audits to ensure that treatment plan reviews are in compliance beginning 9/1/17
D. Clinical supervisors will ensure that any treatment plan falling below will be completed within one week of audit beginning 9/1/17
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