Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in three of six applicable client records reviewed. Client # 1 was admitted on June 7, 2022 and was still active at the time of the inspection. A treatment plan update was completed on August 15, 2022 and the next update was due no later than October 15, 2022; however, the update was not completed until November 1, 2022. Client # 6 was admitted on April 15, 2022 and was discharged on November 15, 2022. A treatment plan update was completed on August 15, 2022 and the next update was due no later than October 15, 2022; however, the update was not completed until November 1, 2022. Client # 7 was admitted on March 22, 2022 and was discharged on August 5, 2022. The individual treatment and rehabilitation plan was completed on April 7, 2022 and the first update was due no later than June 7, 2022; however, the update was not completed prior to discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and executive director with the support of clinical director and quality manager will complete monthly chart audits to ensure treatment plan updates are being completed within policy timeframes. Re-training will occur during group supervision within 30 days, with expectation of full compliance by 6/2/23. |