Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.
Client #1 was admitted on April 27, 2022 and was still active at the time of the inspection. A treatment plan update was completed on July 24, 2022 and the next update was due no later than September 24, 2022; however, the next update was completed on October 7, 2022.
Client #3 was admitted on October 19, 2022 and was still active at the time of the inspection. A treatment plan was completed on October 19, 2022 and the next update was due no later than December 19, 2022; however, it was completed on December 27, 2022.
Client #7 was admitted on March 16, 2022 and discharged on July 14, 2022. A treatment plan update was completed on March 16, 2022 and the next update was due no later than May 22, 2022; however, it was completed on July 1, 2022.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the February 10, 2022 licensing inspection.
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Plan of Correction
DDAP Regulation:
709.92(b) Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed
and updated at least every 60 days.
Plan of Correction:
Treatment Plan Tracker Sheets have been developed so that expiration dates on all clients treatment plans can be referenced every work day. The Program Supervisor will distribute treatment plan tracker sheets to all staff who will be required to keep updated tracker sheets and turn them into Program Supervisor who will review weekly and again in individual supervisions as scheduled to ensure that all treatment plans for all clients are updated at least every 60 days. Upon approval the plan will be executed as early as March 1, 2023.
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