Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in two of six applicable records reviewed.Client #1 was admitted on February 7, 2023 and was still active at the time of the inspection. The facility had a Department-approved exception allowing this client ' s treatment plan updates to be completed every 120 days. A treatment plan update was completed on February 7, 2025 and the next update was due no later than June 9, 2025; however, the update was completed on June 13, 2025. Client #7 was admitted on January 2, 2024 and was still active at the time of the inspection. The facility had a Department-approved exception allowing this client ' s treatment plan updates to be completed every 120 days. A treatment plan update was completed on May 2, 2025 and the next update was due no later than September 2, 2025; however, the update was completed on September 3, 2025. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 29-30, 2024 annual licensing inspection.
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Plan of Correction
Clinical supervisor and Clinic director will hold a staff meeting with counselors on 10/29/25 to discuss that it will now be required that all treatment plans will be signed off and completed timely within 60 days. We will identify the importance of the treatment plans being completed no later than 60 days from the previous treatment plan completion date. We will emphasize the importance of counselors keeping track of any treatment plan completed on a variance from the due date recorded in SMART, so that the treatment plan can be updated appropriately within the 60 days. This information will be reviewed again in clinical supervision on 11/5/25 by the clinical supervisor. This will begin on 1/1/26 and will be monitored on weekly basis by the clinical supervisor and lead counselor. |