Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of four applicable records.
Client #2 was admitted to the outpatient level of care on November 25, 2024 and was active at the time of review. Client #2 ' s record contained a treatment plan dated December 17, 2024. A treatment plan update was due no later than February 17, 2025. The next treatment plan update was completed February 24, 2025.
Client #3 was admitted to the outpatient level of care on December 18, 2024 and was active at the time of review. Client #3 ' s record contained a treatment plan dated December 26, 2024. A treatment plan update was due no later than February 26, 2025. The next treatment plan update was completed March 3, 2025.
Client #4 was admitted to the outpatient level of care on November 19, 2024 and was discharged February 17, 2025. Client #4 ' s record contained a treatment plan dated November 19, 2024. A treatment plan update was due no later than January 19, 2025. The next treatment plan update was completed January 23, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Clinical Manager will review these findings with the therapist and re-educate the therapist on the process to complete treatment plans within the electronic health record as well as the timeline for due dates of treatment plan updates.
The Regional Clinical Manager will audit a minimum of 25% of the patient charts for the therapist over the next 6 months to ensure compliance.
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