Observations
Based on applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in five of seven records. Client #1 was admitted on July 11, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on August 27, 2024, however, there was no documentation of type and frequency of services.Client #2 was admitted on August 29, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on September 4, 2024, however, there was no documentation of type and frequency of services.Client #3 was admitted on December 26, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on January 14, 2025, however, there was no documentation of type and frequency of services.Client #4 was admitted on August 27, 2024 and was discharged on October 15, 2024. A comprehensive treatment and rehabilitation plan was developed with the client on September 4, 2024, however, there was no documentation of type and frequency of services.Client #7 was admitted on August 16, 2024 and was discharged on October 1, 2024. A comprehensive treatment and rehabilitation plan was developed with the client on August 27, 2024, however, there was no documentation of type and frequency of services.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Treatment plans will be corrected to add frequency and type of treatment during the next scheduled review. The electronic health record system was updated to include the option for frequency and type of treatment.
Treatment plans will be monitored for addition of type and frequency over the next 90 days. The electronic health record system settings will be reviewed quarterly with scheduled program updates.
Person responsible: Therapist, Director of Behavioral Health
|