Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven records reviewed.
Client #2 was admitted on July 24, 2024 and was still active at the time of the inspection. A treatment plan update was completed on March 12, 2025 and an update was due no later than May 12, 2025; however, it was not completed until May 19, 2025.
Client #3 was admitted on February 12, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on February 24, 2025 and an update was due no later than April 25, 2025; however, it was not completed until May 15, 2025.
Client #4 was admitted on December 3, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on December 31, 2024 and the next update was due no later than March 1, 2025; however, it was not completed until March 19, 2025.
Client #5 was admitted on November 25, 2024 and was discharged on June 18, 2025. A treatment plan update was completed on February 18, 2025 and an update was due no later than April 19, 2025; however, it was not completed until April 22, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Therapists are provided case reports bi-weekly of treatment plan dates by the D&A Supervisor. Therapists also have access to these reports at any time via the EHR overview.
The Chief Compliance Officer will review and assure that SPU's are completed in a timely manner while she conducts the D&A Audits. Random D&A Audits are completed on a monthly basis.
Community Guidance Center is working on implementing a new treatment plan in the electronic health record which will provide warnings to the therapist when the treatment plan is about to expire to avoid late treatment plans by January 2nd, 2026. |