Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in three of seven applicable records.
Client #2 was admitted to the outpatient level of care on February 12, 2021 and was active at the time of review. Client #2 ' s record contained a treatment plan dated October 20, 2024. The next treatment plan update was due no later than December 20, 2024. The next treatment plan update for client #2 was not completed until December 30, 2024.
Client #3 was admitted to the outpatient level of care on April 11, 2024 and was discharged November 7, 2024. Client #3 ' s record contained a treatment plan dated August 7, 2024. The next treatment plan update was due no later than October 7, 2024. The next treatment plan update for client #2 was not completed until October 14, 2024.
Client #5 was admitted to the outpatient level of care on May 13, 2020 and was active at the time of review. Client #5 ' s record contained a treatment plan dated October 11, 2024. The next treatment plan update was due no later than December 11, 2024. The next treatment plan update for client #5 was not completed until December 12, 2024.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The facility director is ultimately responsible to ensure that the treatment plans are updated as required. The facility director will hold a meeting with the counselors and remind them of the regulation and utilization of the tracking sheet to assist them with compliance. In order to ensure continued compliance random audits will be performed on each caseload. |