Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan with the client and within guidelines established by the facility's policy and procedures manual in three out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days following admission.
Client #1 was admitted on March 17, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 12, 2026; however, it was not completed until April 28, 2026.
Client #3 was admitted on December 16, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than January 16, 2026; however, it was not completed until January 28, 2026.
Client #4 was admitted on October 14, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than November 14, 2025; however, it was not completed until November 17, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Open Arms Recovery Center has revised it's process for tracking treatment plan due dates. Effective August 3, 2026, the review schedule for each client's Peson-Centered Treatment Plan (PTP) will be calculated from the date the client signs the initial PTP. The first treatment plan review will be completed 60 days from the client's signature date, with all subsequent treatment plan reviews completed every 60 days thereafter.
Clinical staff will be educated on the revised tracking process during weekly treatment team meetings to ensure consistency and compliance with regulatory requirements.
The Clinical Supervisor will conduct routine chart audits to verify that treatment plan reviews are completed within the required 60-day timeframe. Any deficiencies identified during audits will be addressed promptly through corrective action and staff coaching. Compliance with treatment plan timeframes will continue to be monitored as part of the agency's ongoing Quality Assurance Program. |