Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in three of seven applicable records reviewed.
Client #1 was admitted on September 17, 2009 and was still active at the time of the inspection. The facility had a Department-approved exception allowing this client ' s treatment plan updates to be completed every 120 days. A treatment plan update was completed on March 13, 2024 and the next update was due no later than July 13, 2024; however, the update was completed on July 18, 2024.
Client #4 was admitted on April 20, 2021 and was discharged on June 28, 2024. A treatment plan update was completed on April 17, 2024 and the next update was due no later than June 17, 2024; however, the update was not completed prior to discharge.
Client #5 was admitted on January 3, 2024 and was still active at the time of the inspection. The facility had a Department-approved exception allowing this client ' s treatment plan updates to be completed every 120 days. A treatment plan update was completed on March 1, 2024 and the next update was due no later than July 1, 2024; however, the update was completed on July 3, 2024. Additionally, the next update was due no later November 3, 2024; however, the update was completed on November 5, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor held a Group Clinical Supervision Meeting with all Counselors on 11/20/24 and reviewed treatment plan documentation and documentation due dates. The clinical team was instructed to review their services due report from the EMR at the beginning of each month and ensure that all treatment plans due are completed in a timely manner to ensure that they are not completed late. The Clinical Supervisor will monitor progress on this goal via the Quality Record Review process, and while he is approving treatment plans. The Clinical Supervisor will also address any trends with individuals during individual clinical supervision.
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