Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans within 60 days in one of two applicable client records.
Client #1 was admitted on November 14, 2022 and discharged on March 2, 2023. A treatment plan was completed on December 12, 2022 and an update was due by February 10, 2023 but no further treatment plan updates were completed prior to clients discharge.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 12, 2022 annual licensing inspection.
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Plan of Correction
Clinical Supervisor will review expectations of clinical documentation and timelines in group/individual supervision by 11/27/23.
The clinical forms audit and treatment plan analysis report in the agency EHR will be reviewed in group and individual supervision to alert clinicians of upcoming treatment plans that need completed.
Progress will me monitored by monthly chart audits and reviewed with clinicians monthly. Quarterly chart audits will also be conducted by CQI Manager to assist in maintaining compliance with timely submission of required documentation.
Any issues noted will be brought to the attention of program management immediately. |