Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan accord to the facility ' s policy and procedure manual in three of six applicable records. The facility ' s policy and procedure manual states that treatment and rehabilitation plans will be updated every seven days for individuals in the partial hospitalization program.Client #11 was admitted to partial hospitalization on May 29, 2024 and was discharged on July 8, 2024. A treatment and rehabilitation plan was developed on June 11, 2024. A treatment and rehabilitation plan update was due no later than June 18, 2024, but was not completed until June 25, 2024.A treatment and rehabilitation plan was developed on June 25, 2024. A treatment and rehabilitation plan update was due no later than July 2, 2024, but was not completed prior to the client ' s discharge.Client #12 was admitted to partial hospitalization on May 28, 2024 and was discharged on July 5, 2024. A treatment and rehabilitation plan was developed on May 28, 2024. A treatment and rehabilitation plan update was due no later than June 4, 2024, but was not completed until June 12, 2024.Client #14 was admitted to partial hospitalization on February 14, 2024 and was discharged on March 20, 2024. A treatment and rehabilitation plan was developed on February 21, 2024. A treatment and rehabilitation plan update was due no later than February 28, 2024, but was not completed until March 12, 2024.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/23/2024, the clinical supervisor updated the policy and procedure manual to comply with state regulations where treatment plan reviews are required every 30 days, instead of weekly. The facility will have an internal policy to review treatment plans more regularly, depending on insurance company regulations, when necessary. A client's primary counselor will be responsible for conducting the treatment plan reviews. The clinical supervisor will conduct weekly chart reviews to ensure all documentation is submitted in the required time frames. |