Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven client records reviewed.
Client #1 was admitted on February 14, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 30, 2024 and the next update was due no later than July 30, 2024; however, there was no update documented in the record until August 12, 2024.
Client #3 was admitted on March 28, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 8, 2024 and the next update was due no later than July 8, 2024; however, there was no update documented in the record at the time of the inspection.
Client #6 was admitted on April 17, 2024 and was discharged on August 7, 2024. A treatment plan update was completed on April 24, 2024 and the next update was due no later than June 24, 2024; however, there was no update documented in the record at the time of the inspection.
Client #7 was admitted on April 4, 2024 and was discharged on July 23, 2024. A treatment plan update was completed on April 18, 2024 and the next update was due no later than June 18, 2024; however, there was no update documented in the record until June 28, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 18, 2023 licensing inspection.
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Plan of Correction
Supervisors will complete re-education with staff on the completing treatment plans and treatment plan updates workflow as well as monitoring treatment plans workflow by 10/4/24. Updates to the Monitoring Treatment Plans workflow have been made to reflect the following changes in process listed below.
-Clinicians dashboards will be pulled weekly from electronic health record by front office and emailed to clinician and supervisor weekly to review any upcoming treatment plans. This document will be an editable working document.
-Clinicians will be responsible to update on the comments section date of completion. Supervisors will review this daily and meet individually with any clinicians that are failing to get the plans completed prior to date on the dashboard. Front office will review weekly differences in dashboards to ensure treatment plans have not expired. |