Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven client records reviewed.
Client #1 was admitted on October 19, 2021 and was discharged on February 15, 2022. A treatment plan was completed on November 23, 2021 and the treatment plan update was due no later than January 23, 2022; however, there was no update documented in the record at the time of the inspection.
Client #4 was admitted on December 16, 2021 and was discharged on April 9, 2022. A treatment plan was completed on January 26, 2022 and the treatment plan update was due no later than March 26, 2022; however, the there was no update documented in the record at the time of the inspection.
Client #7 was admitted on February 2, 2022 and was still active at the time of the inspection. A treatment plan update was completed on May 4, 2022 and the next treatment plan update was due no later than July 4, 2022; however, the treatment plan update was completed on July 12, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervision sessions will be held with each clinician no later than 10/14/22 to address treatment management procedures specific to the treatment plan update process.
All staff will be directed to update treatment plans at least every 30 days for IOP and 60 days for OP. Should the client not attend the scheduled session to develop treatment plans as scheduled, clinical staff will proceed to update the plan as appropriate and document that the plan will be reviewed with the client during the next attended session and updated as needed at that time.
The Clinical Supervisor and Division Director will review treatment plans for compliance during monthly audits. This will be reviewed with Clinical staff in documented regular supervisory sessions. Any outstanding items will be corrected/completed within 48 hours.
The Quality Assurance department will complete at least quarterly reviews, to include audits of treatment plan updates for completion. Any issues noted in this area will result in the development of a performance improvement plan.
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