Observations
Based on a review of client records, the facility failed to document that treatment plans were reviewed and updated at least every 60 days in three of seven client records reviewed.
Client #4 was admitted March 28, 2019 and was discharged January 26, 2021. A treatment plan update was completed on November 15, 2020 and the next update was due no later than January 15, 2020. However, the update was not completed prior to the client's discharge.
Client #5 was admitted November 11, 2019 and was discharged November 30, 2020. A treatment plan update was completed on September 2, 2020 and the next update was due no later than November 3, 2020. However, the update was not completed prior to the client's discharge.
Client #7 was admitted August 25, 2020 and was discharged March 1, 2021. A treatment plan update was completed on November 30, 2020 and the next update was due no later than October 30, 2020. However, the update was not completed prior to the client's discharge.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinicians and Clinical Care Coordinators will be re-trained to schedule and complete a treatment plan at the due date, even if the client is not present. During the re-training, it will be emphasized that these updates must be completed even if a client is in the midst of our discharge process. This training will be completed by 4/30/21. Ongoing compliance will be monitored by the CQI Director via quarterly targeted chart reviews. |