Observations
Based on a review of client records on January 18, 2022, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven client records reviewed.
Client #1 was admitted on May 3, 2021 and was current at the time of the inspection. A treatment plan update was completed on May 26, 2021, and the next update was due by July 26, 2021; however, was not completed until July 27, 2021.
Client #3 was admitted on May 5, 2021 and was current at the time of the inspection. A treatment plan update was completed on November 3, 2021, and the next update was due by January 3, 2022; however, was not completed until January 20, 2021.
Client #4 was admitted on July 1, 2021 and was current at the time of the inspection. A treatment plan update was completed on August 12, 2021, and the next update was due by October 12, 2021; however, was not completed until October 14, 2021.
Client #6 was admitted on April 30, 2021 and was discharged on September 10, 2021. A treatment plan update was completed on June 4, 2021, and the next update was due by August 4, 2021; however, was not completed until August 6, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Director of Outpatient Administration re-trained all program staff on treatment plan timeframes during a team meeting on 2/8/2022. The Office Manager will be responsible for ongoing compliance and will track the completion of treatment plans for all clients. The Office Manager will oversee that clinical staff are re-educated as needed to review and update treatment plans at least every 60 days. |