Observations
Six client records requiring documentation of a treatment plan update were reviewed on August 1, 2016. The facility failed to document a treatment plan update at least every 60 days in client records # 1 and 6.
Client # 1 was admitted on 02/18/16 and discharged on 06/29/16. The comprehensive treatment plan was completed on 2/18/16. A treatment plan updated was due on 4/18/16 and 6/18/2016. The facility failed to document the completion of the first treatment plan update. The second treatment plan update that was due on 6/18/2016 was completed on 6/7/2016.
Client # 6 was admitted on 3/8/2016 and still active at the time of the inspection. The client's master treatment plan was completed on 3/8/16. A treatment plan update was due on 5/8/16. There was no documentation of treatment plan update.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Little Creek Outpatient Services has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted on August 1-2, 2016 in the application of Regulation 709.92(b) LICENSURE Treatment and rehabilitation services
The Clinical Director on 8/4/16 meet with clinical employees. Clinical Director reviewed regulation 709.92(b) regarding type and frequency of treatment plan reviews required as per policy and procedures. Staff was instructed on ensuring these were preformed on all treatment plans as required.
To ensure that this does not reoccur Clinical Director will review all client treatment plans monthly to ensure this requirement is being met. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations
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