Observations
Based on an administrative review, the facility failed to ensure the project director annually updated and signed the written manual delineating the project policies and procedures.
At the time of the inspection, the project director was unable to provide documentation of the last time the manual was updated and signed by them.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By January 27, 2025, the Executive Director will create a sign-off sheet to include name and date the policy and procedure manually is reviewed annually. The board of directors will review the policy and procedures manual in their December meeting each year. The board president will sign the form stating that the manual was reviewed.
If the policy and procedures manual has updates throughout the year, the board president will sign the sign-off sheet during the board meeting the policy changes were reviewed. |
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of seven client records reviewed.
Client # 2 was admitted August 23, 2024 and was active at the time of inspection. The comprehensive treatment plan was completed on September 3, 2024 and the first update was due no later than November 3, 2024; however, the update was not completed until December 4, 2024.
Client # 3 was admitted July 31, 2024, and was active at the time of inspection. The comprehensive treatment plan was completed on August 14, 2024 and the first update was due no later than October 14, 2024; however, the update was not completed until October 23, 2024. Additionally, the next update was due no later than December 23, 2024; however, the update was not completed util January 8, 2025.
Client # 4 was admitted April 9, 2024 and was discharged July 1, 2024. The comprehensive treatment plan was completed on April 16, 2024 and the first update was due no later than June 16, 2024; however, the update was not completed until June 25, 2024.
Client# 5 was admitted July 2, 2024, and was discharged November 25, 2024. The comprehensive treatment plan was completed on July 17, 2024 and the first update was due no later than September 17, 2024; however, the update was not completed until September 25, 2024.
This is a repeat citation from the February 21, 2024 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During monthly supervision beginning February 6, 2025, the Executive Director will review with clinical staff the policy and regulations that govern treatment plan updates. The executive director will explain to clinical staff that the client does not need to sign off on the treatment plan update. They will also be directed to have the client sign the plan during their next session to avoid completing the update late. This will be reviewed monthly and audited by the clinical supervisors at least monthly as well.
The counselor for client #2, will meet with the executive director by 02/13/25 to review their specific treatment plan updates and discuss a plan of action so that updates are not late in the future. Will audit counselor's charts monthly for next 6 months to ensure compliance.
The counselor for client #3, will meet with the counselor by 02/13/2025 and explain the policy and regulation for treatment plan updates. Will audit counselor's charts monthly for next 6 months to ensure compliance.
The counselor for client #4, will meet with the counselor by 02/13/2025 and explain the policy and regulation for treatment plan updates. Will audit counselor's charts monthly for next 6 months to ensure compliance.
The counselor for client #5, will meet with the counselor by 02/13/2025 and explain the policy and regulation for treatment plan updates. Will audit counselor's charts monthly for next 6 months to ensure compliance.
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