Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of four applicable client records reviewed.
Client # 5 was admitted on December 4, 2024 and was discharged on September 12, 2025. A treatment plan update was completed on April 3, 2025 and the next update was due no later than June 3, 2025; however, the update was not completed until July 29, 2025.
Client # 6 was admitted on October 14, 2024 and was discharged on June 1, 2025. A treatment plan update was completed on January 29, 2025 and the next update was due no later than March 29, 2025; however, the update was not completed until April 29, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed the identified deficiencies with staff members on 2/20/2026. EHR has been set up to provide clinicians with a report to show upcoming paperwork due dates. Director and office manager will review the treatment plan due date report on a weekly basis to ensure all updates are completed within 60 days. Any treatment plan approaching its due date without completion will be addressed directly with the assigned clinician.
Treatment plan compliance will also be added as a standing agenda item during biweekly clinical supervision meetings.
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