Observations
Based on the review of client records, the facility failed to document that treatment plans were reviewed and updated at least every 60 days in four of seven client records reviewed. Client #2 was admitted July 30, 2019 and was active at the time of inspection. A treatment plan update was completed on December 26, 2019 and a treatment plan update was due no later than February 26, 2019. However, the treatment plan was not completed at the time of inspection. Client #3 was admitted September 24, 2019 and was active at the time of inspection. A treatment plan update was completed on October 16, 2019 and a treatment plan update was due no later than December 16, 2019. However, the treatment plan was not completed until January 6, 2020.Client # 5 was admitted September 30, 2019 and was discharged January 30, 2020. A treatment plan update was completed on November 26, 2019 and a treatment plan update was due no later than January 26, 2020. However, the treatment plan was not completed at the time of inspection. Client # 6 was admitted March 4, 2019 and was discharged September 10, 2019. A treatment plan update was completed on May 14, 2019 and a treatment plan update was due no later than July 14, 2019. However, the treatment plan was not completed until July 18, 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff meeting was held on 3/9/20 to discuss Licensure issue 709.92. Clinicians received a handout from the supervisor that outlined requirements for treatment plan completion timelines. This document included information regarding the need for a treatment plan updates to be completed and signed within 60 days from the date that the client is evaluated and that all subsequent treatment plans are to be updated and submitted every 60 days. Clinicians were reminded that if for any reason they are unable to obtain a client signature on a treatment plan update to update and sign the treatment plan by the due date, have the client sign the treatment plan during the next session and to add a memo to chart noting why the signature was unable to be obtained. Clinicians were also given a handout outlining how to create configured alerts in Care Logic to make it easier to keep track of the due date of upcoming treatment plan updates in the documentation system. Supervisor will check in with clinicians 1x per month on progress with configuring alerts and to offer reminders about treatment plan updates every 60 days in Care Logic. |