Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of seven records reviewed.
Client #1 was admitted on July 2, 2025 and was discharged on October 2, 2025. A comprehensive treatment plan was completed on July 9, 2025 and an update was due no later than September 9, 2025; however, it was not completed until October 2, 2025.
Client #2 was admitted on May 22, 2025 and was still active at the time of the inspection. A treatment plan update was completed on July 28, 2025 and an update was due no later than September 28, 2025; however, it was not completed until September 30, 2025.
Client #3 was admitted on July 1, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on July 16, 2025 and an update was due no later than September 16, 2025; however, it was not completed until October 1, 2025.
Client #6 was admitted on April 10, 2025 and was discharged on July 9, 2025. A comprehensive treatment plan was completed on April 23, 2025 and an update was due no later than June 23, 2025; however, it was not completed until July 9, 2025.
Client #7 was admitted on March 21, 2025 and was discharged on August 28, 2025. A comprehensive treatment plan was completed on March 27, 2025 and an update was due no later than May 27, 2025; however, it was not completed until June 19, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In part as a response to this observation, Blueprints leadership created a Lead Program Therapist position for the Colonial Village site; one of the chief responsibilities of the role is the oversight of both newly reinstated peer chart reviews and also of the timeliness of outpatient records for the census as a whole. This Lead Program Therapist will weekly utilize previously established improvements to the census and to Blueprints' EMR, Kipu to expediently track which clients require a treatment plan update each week in order to maintain compliance. The Lead Program Therapist accepted the position and responsibility on 10/31/2025.
The Compliance Officer also began a weekly review of the Outpatient census to identify any Treatment Plan Update documents expected to be completed within the week and issuing reminders to clinical leadership as the result of the weekly monitoring. Doing so will ensure that if the responsibilities required of the Lead Program Therapist exceed their capacity or the capacity of a single individual, issues will be caught and addressed immediately.
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