Observations
The facility failed to ensure that it updated client treatment and rehabilitation plans at least once every 60 days in 3 of 5 applicable records reviewed during the on-site inspection.
A total of 7 client records were reviewed during the on-site inspection, 5 of which required treatment and rehabilitation plan updates.
Client #1 was admitted for treatment on 08/14/2018, and was an active client at the time of the on-site inspection. The client's individualized treatment plan was dated 10/09/2018, but there was no documented treatment plan update at the time of the on-site inspection.
Client #5 was admitted for treatment on 02/19/2018, and was discharged on 08/17/2018. The last documented treatment plan update for the client was completed on 05/15/2018.
Client #6 was admitted for treatment on 10/02/2017, and was discharged on 09/21/2018. The last documented treatment plan update for the client was completed on 05/14/2018.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
It shall be the responsibility of the Facility Director to ensure that treatment plan updates are being updated every 60 days. The Facility Director will instruct the counselor to complete treatment plans at 45 days if possible, in the event of a missed appointment. In addition, for no show clients or clients who are expected to have an extended absence, the Facility Director will instruct the counselor to complete an updated treatment plan in the patient's absence at 60 days at the latest. Client #1's treatment plan was updated 12/7/18. |