Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in five of seven client records reviewed.
Client # 1 was admitted February 20, 2023 and was active at the time of inspection. A treatment plan update was completed on July 20, 2023 and the next update was due no later than September 20, 2023; however, the update was not completed until October 20, 2023.
Client # 2 was admitted July 7, 2023 and was active at the time of inspection. The comprehensive treatment plan was completed on July 7, 2023 and a treatment plan update was due no later than September 7, 2023; however, the update was not completed until September 29, 2023.
Client # 3 was admitted February 20, 2023 and was active at the time of inspection. A treatment plan update was completed on May 24, 2023 and the next update was due no later than July 24, 2023; however, the update was not completed until August 23, 2023.
Client # 5 was admitted January 12, 2023 and was discharged October 2, 2023. A treatment plan update was completed on April 10, 2023 and the next update was due no later than June 10, 2023; however, the update was not completed until July 31, 2023.
Client # 6 was admitted November 24, 2020 and was discharged October 16, 2023. A treatment plan update was completed on March 2, 2023 and the next update was due no later than May 2, 2023; however, the update was not completed prior to the client's discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients who are active in treatment will have their treatment plans reviewed and updated at least every 60 days. JFK is implementing an electronic monitoring/tracking system that involves staff, clinical supervisor and Quality Assurance staff, which will alert all involved of the required completion dates of the documentation. The Clinical supervisor is responsible for reviewing the electronic monitoring/tracking system to identify required updated treatment plans. Counselors will be instructed by the clinical supervisor to complete the identified treatment plans prior to expiration. Quality Assurance staff will also monitor the completion and compliance of this practice during chart reviews. |