Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven records reviewed.
Client #1 was admitted on September 16, 2025 and was still active at the time of the inspection. A treatment plan update was completed on November 4, 2025 and an update was due no later than January 4, 2026; however, it was not completed until January 13, 2026.
Client #2 was admitted on August 14, 2025 and was still active at the time of the inspection. A treatment plan update was completed on October 31, 2025 and an update was due no later than December 31, 2025; however, it was not completed until January 16, 2025.
Client #4 was admitted on April 24, 2025 and was still active at the time of the inspection. A treatment plan update was completed on June 26, 2025 and the next update was due no later than August 26, 2025; however, it was not completed until September 5, 2025.
Client #5 was admitted on August 15, 2025 and was discharged on December 12. 2025. A comprehensive treatment plan was completed on August 15, 2025 and an update was due no later than October 15, 2025; however, it was not completed until October 24, 2025.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the December 17, 2024 licensing inspection.
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Plan of Correction
In an effort to address citation 709.92 (b), the following will be implemented:
Beginning on 1/28/2026, the Clinical Supervisor will train all clinicians on two options for the timely completion of all treatment plans.
1. Clinicians will complete the updated treatment plan with the client prior to the 60-day time frame so it may be early but not late.
2. If the client does not attend their scheduled appointment that is closest to the treatment plan update due date, the counselor will complete the updated treatment plan by the 6oth day.
The Program Director will monitor the progress of this action step during the monthly supervision with the Clinical Supervisor. |