Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of five applicable client records reviewed.
Client #5 was admitted on May 9, 2023, and was discharged on October 16, 2023. A comprehensive treatment plan was completed on May 30, 2023 and the next update was due no later than July 30, 2023; however, the next documented treatment plan update was August 2, 2023.
Client #7 was admitted on September 18, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was completed on November 20, 2023, and the next update was due no later than January 20, 2024; however, the next documented treatment plan update was January 25, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all requirements regarding treatment and rehabilitation services, and specifically regarding updating treatment plans at least every 60 days.
Each of the late treatment plans identified above were conducted late due to client attendance issues and our clinical preference to complete the treatment plan with the client in the office. We recognize however that the regulation takes precedence, and that the treatment plan needs to be completed every 60 days even if the client misses their scheduled treatment planning appointment.
All clinical supervisors have been retrained on the necessary requirements of a treatment plan including the requirement to update treatment plans at least every 60 days even if the client is not in the office. The clinical supervisors will be reviewing this with all clinical staff in clinical supervision. Additionally, the clinical supervisors will be confirming that treatment plans are completed fully and updated at least every 60 days prior to their signing off on the treatment plan. In addition, our compliance team has been retrained on treatment plan requirements and will be further monitoring this item while conducting file audits. Lastly, the director will follow up quarterly to ensure continued compliance.
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