Observations
The facility failed to document treatment plan review and updates at least every 60 days, in four of seven client records.
Eight outpatient client records were reviewed on September 5-7, 2017. Seven client records required treatment plan review and updates. The facility failed to document treatment plan review and updates at least every sixty days, in client records # 11, 12, 13 and 14.
Client #11 was stepped down from partial hospitalization to outpatient on 4/21/17 and was discharged on 6/15/17. There was only one treatment plan documented in Client #11's record, and it was dated 4/9/17.
Client #12 was stepped down from partial hospitalization to outpatient on 4/14/17 and was discharged on 8/25/17. There was only one treatment plan documented in Client #12's record, and it was dated 4/21/17.
Client #13 was stepped down from partial hospitalization to outpatient on 5/1/17 and was discharged on 8/2/17. A treatment plan dated 4/4/17 was completed and the next review would have been due by 6/4/17; however, it was completed on July 7, 2017.
Client #14 was stepped down from partial hospitalization to outpatient on 12/28/16 and discharged on 8/9/17. Treatment plan reviews were completed on 3/13/17 and 5/12/17; however, there was no treatment plan review documented for July 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Outpatient staff will be re-educated that the treatment plan reviews need completed at least every 60 days by the Outpatient Supervisor. The Outpatient Supervisor and the Outpatient Manager will review paperwork completion monthly to ensure treatment plan reviews are completed in a timely manner. This will be completed by 10/31/2017. |