Observations
Based on a review of eight client records on October 3, 2017, the facility failed to complete sixty day treatment plan updates in four of five required client records.
Client #2 was admitted on 4/4/16 and the most recent updated plans were March 15, 2017, May 16, 2017 and July 20, 2017.
Client #6 was admitted on 4/13/2017 and was discharged on 7/25/2017. The comprehensive treatment plan was dated June 8, 2017 and the treatment plan update was August 10, 2017.
Client #7 was admitted March 10, 2017 and is still an active client. His comprehensive treatment plan was dated April 5, 2017 and the treatment plan update was June 27, 2017.
Client #8 was admitted on 4/17/2017 and is still an active client. The comprehensive treatment plan was dated July 9, 2017 and the treatment plan update was September 28, 2017.
The findings were reviewed with the facility during the licensing process.
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Plan of Correction
Corporate Clinical Coordinator trained staff on treatment plan update completion. Program Director has discussed this issue in several staff meetings to date. This will be monitored through monthly open and closed chart monitors. In addition, Program Director has developed a specialized report in new EMR to monitor treatment plan compliance. Clinical Supervisor has reviewed report for all active clients to date and has resolved all outstanding tx. plan updates. Ongoing, the Clinical supervisor will review report weekly with clinical staff to maintain compliance. Complete compliance as of 11/10/2017. |