Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in five of seven applicable records.
Client #1 was admitted to outpatient on March 9, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on March 9, 2023. A treatment and rehabilitation plan update was due no later than May 9, 2023, but was not completed until December 22, 2023.
Client #3 was admitted to outpatient on June 26, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on June 26, 2023. A treatment and rehabilitation plan update was due no later than August 26, 2023, but was not completed until October 6, 2023.
Client #4 was admitted to outpatient on April 27, 2023 and discharged on July 25, 2023. A treatment and rehabilitation plan was developed on April 27, 2023. A treatment and rehabilitation plan update was due no later than June 27, 2023, but was not completed until July 9, 2023.
Client #5 was admitted to outpatient on May 31, 2023 and discharged on October 10, 2023. A treatment and rehabilitation plan was developed on May 31, 2023. A treatment and rehabilitation plan update was due no later than July 31, 2023, but was not completed until October 10, 2023.
Client #6 was admitted to outpatient on June 21, 2023 and discharged on November 6, 2023. A treatment and rehabilitation plan was developed on June 21, 2023. A treatment and rehabilitation plan update was due no later than August 21, 2023, but was not completed until September 18, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 1, 2023 annual licensing inspection.
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Plan of Correction
Clinical Supervisor will facilitate weekly group staffing/supervision on 2/1/2024 and will include a review of the SPHS internal policy and DDAP Regulatory Standards for Treatment Plan updates and related time frames ensuring that treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. Of particular focus will be re-training that focuses on the importance of these updates being completed even if the client has not been actively attending their sessions. A group supervision form will be completed and signed by all clinical staff acknowledging they have been re-trained in this requirement. Clinical staff that are not present, based on their in-office availability, will review the information with the Clinical Supervisor or Team Leader at their next scheduled individual supervision and will sign the individual supervision log confirming re-training of this requirement. A copy of both the group supervision form and each individual supervision log will be sent to the Clinical Director to confirm that the training occurred. Clinical staff will be expected to complete and maintain a list of current treatment plan completion and update dates to be shared and discussed with the Clinical Supervisor or Team Leader at each individual supervision. In addition, clinical staff will be trained on how to extract data from the EHR record to confirm any upcoming treatment plan updates that are coming due. Performance improvement plans or action plans will follow if staff are not completing these items timely. The clinical supervisor and/or their delegate will review treatment plan completion monthly to ensure that all staff are adequately completing these items. Random chart reviews will be documented in the client record through either the Chart Review service in the EHR or scanned into the client chart. A mock audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will confirm that treatment plan updates are occurring as required throughout an individual's treatment. |