Observations
Based on a review of client records on February 16, 2022, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven client records reviewed.
Client #3 was admitted on June 10, 2021 and was current at the time of the inspection. A treatment plan update was completed on September 8, 2021, and the next update was due by November 7, 2021; however, was not completed until November 9, 2021.
Client #4 was admitted on May 21, 2021 and was current at the time of the inspection. A treatment plan update was completed on December 13, 2021, and the next update was due by February 12, 2022; however, was not completed until February 14, 2021.
Client #7 was admitted on April 6, 2021 and was discharged on September 20, 2021. A treatment plan update was completed on April 20, 2021, and the next update was due by June 19, 2021; however, was not completed until June 21, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Office Manager and Clinical Supervisor re-trained all staff on treatment plan timeframes during a team meeting on 2/23/2022. The Office Manager will be responsible for ongoing compliance and will track the completion of treatment plans for all clients. The Office Manager will oversee that clinical staff are re-educated as needed to review and update treatment plans at least every 60 days. |