Observations
Based on applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in three of seven records.
Client #2 was admitted on February 27, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on March 28, 2023. A treatment and rehabilitation plan update was due no later than May 28, 2023, but was not completed until May 30, 2022.
Client #5 was admitted on January 24, 2022 and discharged on May 9, 2023. A treatment and rehabilitation plan was developed on August 3, 2022. A treatment and rehabilitation plan update was due no later than October 3, 2022, but was not completed until October 6, 2022.
A treatment and rehabilitation plan was developed on January 19, 2023. A treatment and rehabilitation plan update was due no later than March 19, 2023, but was not completed until March 23, 2023.
Client #6 was admitted on October 5, 2022 and discharged on June 5, 2023. A treatment and rehabilitation plan was developed on February 16, 2023. A treatment and rehabilitation plan update was due no later than April 18, 2023, but was not completed until April 20, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and/or Clinical Supervisor will hold a staff training related to treatment planning and treatment plan updates. Facility Director will maintain on-site for review documentation of the date of training, information covered as well as a list of staff present. Clinical Supervisor will monitor compliance with the treatment planning update timeframes through random chart auditing. Documentation will be maintained on-site for review as needed. |