Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in two of four records.
Client #4 admitted June 3, 2025 and discharged September 16, 2025. A treatment plan was completed on June 3, 2025 and the update was due by August 2, 2025 but not completed until August 18, 2025.
Client #5 admitted August 6, 2024 and discharged October 20, 2025. A treatment plan was completed on June 10, 2025 and the update was due by August 9, 2025 but not completed until August 18, 2025. Additionally, another update was due by October 17, 2025 but not completed prior to discharge.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Department staff will meet on 2/18/2026 and review the deficiencies identified in the on site inspection from DDAP. Department staff will review the policies and procedures that relate to this identified deficiency.
The Project Director will be responsible for generating a caseload report on Mondays to identify treatment plan time frames and deadlines for each staff member. The caseload report will be provided to the clinical staff for updates and review with client. The clinician will be responsible for updating the treatment plan within the identified time frame.
The Project Director will be responsible for ensuring that treatment plans are completed as identified by the end of the business week. Any barriers to these time frames will be clearly documented in a written supervision note that both the clinician and the Project Director have access to.
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