Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in six out of six applicable records reviewed.
Client #1 was admitted on December 4, 2024 and was still active at the time of the inspection. The treatment plan was dated December 4, 2024.
Client #2 was admitted on October 10, 2024 and was still active at the time of the inspection. The treatment plan was dated October 10, 2024.
Client #3 was admitted on January 6, 2025 and was still active at the time of the inspection. The treatment plan was dated January 6, 2025.
Client #4 was admitted on September 23, 2024 and was still active at the time of the inspection. The treatment plan was dated September 23, 2024.
Client#5 was admitted on August 14, 2024 and discharged on December 2, 2024. The treatment plan was dated August 12, 2024.
Client #6 was admitted on August 7, 2024 and was discharged on October 29, 2024. The treatment plan was dated August 7, 2024.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 11, 2024 licensing inspection.
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Plan of Correction
790.92a3 The Facility Directors will meet with the Clinical Director regarding needed changes to the Treatment Plan document in Carelogic. The Clinical Director will revise the Treatment Plan document in the agency's ECR to include the proposed type of support service. This will be in compliance by 6/16/25. Compliance with this standard will be monitored and enforced by the Facility Directors and Clinical Coordinators through staff training, quality reviews and supervision. |