Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in two of four applicable records.
Client #1 was transferred from higher level of care in project to partial hospitalization on February 20, 2025 and was discharged on April 10, 2025. A treatment and rehabilitation plan was updated on February 19, 2025 prior to transfer from higher level of care within the project. A treatment and rehabilitation plan update was due no later than March 21, 2025, but was not completed until March 31, 2025.
Client #4 was transferred from higher level of care in project to partial hospitalization on May 30, 2025 and was discharged on July 3, 2025. A treatment and rehabilitation plan was updated on May 23, 2025 prior to transfer from higher level of care within the project. A treatment and rehabilitation plan update was due no later than June 23, 2025, but was not completed until June 27, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All treatment plans will be reviewed and signed off on by the therapist when a client transfers from Residential to PHP or IOP. This will ensure treatment plans are current, clinically appropriate, and aligned with regulatory requirements at each level of care.
Treatment plan reviews in PHP and IOP will be extended to 60 days, which is consistent with DDAP regulations. The Clinical program manager will change the policies to reflect the new 60 day due date. All clinical staff will receive a refresher training on treatment plan reviews, internal documentation standards, and the new supervision/review process. This training will occur within the next two weeks. The clinical program manager and the Lead therapist will ensure sustained compliance by monitoring this monthly.
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