Observations
Based on a review of client records, the facility failed to document treatment plan updates at least every 60 days in four of six client records.
Client #4 was admitted on April 16, 2021 and discharged on October 11, 2021. The last treatment plan update was documented on May 10, 2021. Treatment plan updates were due to be completed by July 10 and September 10, 2021.
Client #5 was admitted on April 15, 2021 and discharged on October 7, 2021. A treatment plan update was documented on June 30, 2021. A treatment plan update was due to be completed by August 30, 2021. The treatment plan update was documented on September 20, 2021.
Client #6 was admitted on May 25, 2021 and discharged on November 5, 2021. The last treatment plan update was documented on June 8, 2021. A treatment plan update was due to be completed by August 8 and October 8, 2021.
Client #7 was admitted on May 6, 2021 and discharged on February 16, 2022. A treatment plan update was documented on September 3, 2021. A treatment plan update was due to be completed by November 3, 2021 and January 3, 2022. A treatment plan update was documented on December 29, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor trained all clinical staff on the importance of documenting that treatment plans were reviewed and updated at least every 60 days on March 25, 2022. The
Clinical Supervisor will monitor compliance with documenting that treatment plans were reviewed and updated at least every 60 days during weekly chart audits with counselors in supervision sessions on an ongoing basis beginning on the week of April 4, 2022. The administrative assistant will send treatment plan update reminder messages on the computer system to the staff and will train the staff on how to set up a reminder on or before April 15, 2022. |