Observations
Based on a review of client records, the facility failed to complete treatment plan updates in accordance with agency policy and procedure in five of seven records.Agency policy requires treatment plan updates every 30 days for clients in the intensive outpatient (IOP) level of care and every 60 days for clients in the outpatient level of care. Client #1 admitted to IOP level of care on March 20, 2025; stepped down to outpatient on June 5, 2025; discharged on August 26, 2025. A treatment plan completed June 5, 2025 required an update by August 4, 2025. No update was completed prior to discharge.Client #2 admitted to IOP level of care on February 4, 2025 and discharged on April 25, 2025. A treatment plan completed February 4, 2025 required an update by March 6, 2025, but it was not completed until March 7, 2025. The next update was due April 6, 2025 but not completed until April 12, 2025.Client #4 admitted to IOP on January 13, 2025; stepped down to outpatient on March 13, 2025; discharged on May 29, 2025. A treatment plan completed March 13, 2025 required an update by May 12, 2025, but it was not completed until May 15, 2025.Client #6 admitted to IOP on January 14, 2025; stepped down to outpatient on March 11, 2025; discharged on June 19, 2025. A treatment plan completed March 11, 2025 required an update by May 10, 2025. No updates were completed prior to discharge.Client #7 admitted to IOP on February 20, 2025; stepped down to outpatient on April 10, 2025; discharged on June 26, 2025. A treatment plan completed February 24, 2025 required an update by March 26, 2025, but it was not completed until April 2, 2025.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director has changed center policy and now requires all IOP treatment plans to be updated within 30 days and all OP treatment plans to be updated within 60 days. Office Coordinator will monitor this weekly while monitoring charts and will inform staff of impending treatment plans. Clinical staff will also use a reminder that is built into the medical record to remind the clinical staff to update necessary treatment plans. |
Observations
Based on a review of client records, the facility failed to document follow-up attempts with clients following discharge in three of six applicable records. Agency policy requires a follow-up contact within 30 days of discharge. Client #2 admitted on February 4, 2025 and discharged on April 25, 2025. A follow up attempt was due by May 25, 2025 but not completed until June 19, 2025. Client #4 admitted on January 13, 2025 and discharged on May 29, 2025. A follow up attempt was due by June 28, 2025 but not completed until August 1, 2025. Client #7 admitted on February 20, 2025 and discharged on June 26, 2025. A follow up attempt was due by July 26, 2025 but not completed until August 1, 2025.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will monitor office staff to ensure that follow up calls are being made within the established 30 day limit. Office staff shall be required to set reminders in their electronic calendar and will include Project Director in the electronic reminder to ensure that calls are being made within the 30 day time limit. |