Observations
Based on a review of client records, the facility failed to document treatment plan updates at least every 60 days in three of seven client records.
Client #4 was admitted on April 22, 2021 and discharged on January 12, 2022. The last treatment plan update was documented on October 29, 2021. A treatment plan update was due to be completed by December 29, 2021.
Client #5 was admitted on June 21, 2021 and discharged on February 9, 2022. The last treatment plan update was documented on November 4, 2021. A treatment plan update was due to be completed by January 4, 2022.
Client #7 was admitted on July 22, 2021 and discharged on December 31, 2021. A treatment plan was documented on July 22, 2021. A treatment plan update was due to be completed by September 22, 2021 and November 22, 2021. A treatment plan update was documented on October 26, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor trained all clinical staff on the importance of documenting that treatment plans were reviewed and updated at least every 60 days on March 25, 2022. The
Clinical Supervisor will monitor compliance with documenting that treatment plans were reviewed and updated at least every 60 days during weekly chart audits with counselors in supervision sessions on an ongoing basis beginning on the week of April 4, 2022. The administrative assistant will send treatment plan update reminder messages on the computer system to the staff and will train the staff on how to set up a reminder on or before April 15, 2022. |