Observations
Based on a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client in four of seven applicable client records reviewed.
Client #5 was admitted to the outpatient activity on May 22, 2025 and was discharged on August 15, 2025. The individual treatment and rehabilitation plan was signed and dated by facility staff on June 10, 2025; however, there was no written documentation indicating the plan was developed with the client.
Client #6 was admitted to the outpatient activity on May 29, 2025 and was discharged on August 28, 2025. The individual treatment and rehabilitation plan was signed and dated by facility staff on June 18, 2025; however, there was no written documentation indicating the plan was developed with the client.
Client #7 was admitted to the outpatient activity on May 20, 2025 and was discharged on August 18, 2025. The individual treatment and rehabilitation plan was signed and dated by facility staff on June 17, 2025; however, there was no written documentation indicating the plan was developed with the client.
Client #8 was admitted to the outpatient activity on June 10, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on June 12, 2025; however, there was no written documentation indicating the plan was developed with the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director conducted a staff training about the updated treatment plan policy and procedure to all clinical staff members on 2/13/26.
The training focused on the adherence of the documentation of our client's active participation in their treatment plan development in the Outpatient level of care. Effective 2/16/26, the primary therapist will document the client's participation in the development of their master treatment plan in the client's chart in each level of care (e.g. Partial Hospitalization and Outpatient treatment).
The Facility Director will implement a new chart review process starting 2/16/26 and will perform a random monthly audit to ensure compliance with this process in treatment planning. |