Observations
Based on a review of client records, the facility failed to document treatment plan updates every 30 days in one of two applicable records.
Client #1 was admitted to the partial level of care on March 3, 2026, and discharged on April 15, 2026. A treatment plan was completed on March 3, 2026, and an update was due no later than April 3, 2026; however, there were no updates in the record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Counselors were reeducated, 7.23.2026, on treatment plan review due dates for all level of care as well as the use of their case trackers to monitor due dates of treatment plan reviews. Counselors will review case trackers daily to ensure that they are completing reviews as needed and by their due dates and email ED by end of week with final updates made. ED will review case trackers in supervisions and discuss barriers to completing treatment plans with any clients. Administrative Assistant will utilize Treatment Plan Compliance Report weekly and will email list of any updates needed to staff and ED every Thursday to ensure clients have active treatment plans. |