Observations
Based on a review of client records, the facility failed to ensure all treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of three applicable client records reviewed.
Client #1 was admitted on November 11, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on December 3, 2025 and a treatment plan update was due no later than February 3, 2026; however, the update was not completed at the time of inspection.
Client #4 was admitted on March 28, 2025 and was discharged on August 25, 2025. The individual treatment and rehabilitation plan was completed on April 7, 2025 and a treatment plan update was due no later than June 7, 2025; however, the update was completed on July 10, 2025.
Client #5 was admitted on April 10, 2025 and was discharged on October 20, 2025. The individual treatment and rehabilitation plan was completed on April 16, 2025 and a treatment plan update was due no later than June 16, 2025; however, the update was completed on June 25, 2025.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
1. Facility director/supervisor reviewed findings from DDAP audit with SUD clinician on February 13, 2026 during individual clinical supervision.
2. Supervisor conducted a training session on February 20, 2026 with SUD clinician to review the DDAP requirements for treatment plan updates, emphasizing the 60 day review/update standard. Reviewed best practices for measurable, client-centered treatment planning and the importance of timely documentation.
3. Clinician was directed to review treatment plan alerts in EMR at least weekly to identify upcoming updates. After the completion of each initial treatment plan, clinician will immediately schedule individual session for treatment plan update in EMR to ensure timely completion within the 60 day window.
4. Clinician will conduct monthly chart audits that will be reviewed in at least 1 supervision meeting monthly. For any issues identified, clinician will be given up to 2 weeks to make necessary corrections.
5. For Client #1, the client disengaged in treatment and the clinician began outreach attempts prior to the audit. Client attended no further treatment and was discharged without a treatment plan update. Supervisor provided feedback to the clinician that all treatment plan updates need to occur prior to their expiration date even if a client is disengaging in treatment. Clinician understands that he will need to complete all treatment plan updates and sign them on time even if the client is not present.
|