Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 30 days in three of seven applicable records.
Client #4 was admitted to the inpatient level of care on October 7, 2024 and was discharged March 6, 2025. Client #4's record contained a treatment plan update dated January 30, 2025. The next treatment plan update was due no later than March 1, 2025; however, no further treatment plan updates were found in Client #4 ' s record.
Client #5 was admitted to the inpatient level of care on October 17, 2024 and was discharged February 11, 2025. Client #5 ' s record contained a treatment plan update dated December 23, 2024. The next treatment plan update was due no later than January 23, 2025; however, the next treatment plan update was not completed until January 30, 2025.
Client #8 was admitted to the inpatient level of care on November 25, 2024 and was discharged March 14, 2025. Client #8's record contained a treatment plan update dated December 17, 2024. The next treatment plan update was due no later than January 17, 2025; however, the next treatment plan update was not completed until February 17, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately Clinical Manager will run a weekly report in the electronic medical record to identify clients with a treatment plan expiring within the next 7 days and coordinate with clinical staff to ensure the treatment plan is updated prior to expiring. Clinical manager will discuss barriers to completing treatment plan in a timely manner and the clinical team will collaborate to overcome any barriers to completion. Documentation for late treatment plans will be included in the electronic medical record to outline extenuating circumstances that may occur. Clinical Manager will complete weekly chart reviews to ensure treatment plans are completed within a timely manner. A weekly clinical review will be sent to the Director and Service Line Director. In the absence of a Clinical Manger, these steps will be completed by the Program Director. |