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 two of four applicable client records reviewed.
Client # 10 was admitted to the outpatient activity on July 8, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 5, 2022, and the first update was due no later than October 5, 2022; however, there was no update completed at the time of the inspection.
Client # 11 was admitted to the outpatient activity on April 3, 2022 and was discharged on September 15, 2022. The individual treatment and rehabilitation plan was completed on May 9, 2022 and the first update was due no later than July 9, 2022; however, there was no update completed prior to discharge.
This is a repeat citation from the November 18, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director has reviewed regulations pertaining to treatment plan reviews being updated at least every 60 days.
The primary therapist for the identified patients still admitted that were missing treatment plan reviews was notified immediately. The treatment plan for client #10 who admitted on July 8, 2022 was updated on 11/16/22. The treatment plan will be updated again no later than 1/16/23.
The ensure this deficiency does not recur, the program director will conduct monthly chart audits to ensure that treatment plans are reviewed and updated within the specified time frames. At least one of the audits per month will include clients in OP LOC.
A staff training will be scheduled for 11/30/22 to review treatment plan update protocols. |