Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in three of seven applicable records reviewed.
Client #4 was admitted on June 23, 2021 and was discharged on June 5, 2024. The facility had a Department-approved exception allowing this client ' s treatment plan updates to be completed every 120 days. A treatment plan update was completed on December 14, 2023 and the next update was due no later than April 14, 2024; however, the update was completed on April 19, 2024.
Client #6 was admitted on November 27, 2023 and was still active at the time of the inspection. A treatment plan update was completed on March 19, 2024 and the next update was due no later than May 19, 2024; however, the update was completed on May 22, 2024. Additionally, the next update was due no later than July 22, 2024; however, the update was completed on July 23, 2024. Also, the next update was due no later than September 23, 2024; however, the update was completed on September 24, 2024.
Client #7 was admitted on May 16, 2022 and was still active at the time of the inspection. The facility had a Department-approved exception allowing this client ' s treatment plan updates to be completed every 120 days. A treatment plan update was completed on September 27, 2023 and the next update was due no later than January 27, 2024; however, the update was completed on January 31, 2024. Additionally, the next update was due no later May 31, 2024; however, the update was completed on June 7, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Comprehensive Treatment Plans will now be completed using the due date, rather than the intake date. This change will be implemented through a training done during the week of 11/18--11/22. The Clinical Supervisor will monitor for compliance during weekly/monthly supervision, along with spot-checks when approving Treatment Plans. |