Observations
Based on a review of seven client records, the facility failed to document written acknowledgement that one client had been notified of the client rights.
Clint #2 was admitted on March 22, 2021 and was current at the time of the inspection, there was no written acknowledgement in the client record that they had been notified of the client rights.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Regional Director of Outpatient Administration will oversee that Client #2 completes written acknowledgement of client rights at the next scheduled appointment on 2/11/2022. The Director of Outpatient Administration also provided re-education to all clinical staff on 2/1/2022 to reinforce that all necessary documentation be completed during a client's intake. The Office Manager will be responsible for reviewing completed intake packets to ensure ongoing compliance. |
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 three out of seven client records reviewed.
Client #1 was admitted on July 12, 2021 and was current at the time of the inspection. A treatment plan update was completed on August 24, 2021, and the next update was due by October 24, 2021; however, was not completed until October 27, 2021.
Client #4 was admitted on May 20, 2021 and was current at the time of the inspection. A treatment plan update was completed on October 14, 2021, and the next update was due by December 13, 2021; however, was not completed until December 16, 2021.
Client #5 was admitted on April 22, 2021 and was discharged on December 9, 2021. A treatment plan update was completed on September 23, 2021, and the next update was due by November 22, 2021; however, was not completed until December 2, 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 will oversee that all program staff are re-trained on treatment plan timeframes during a team meeting on 2/14/2022. 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. |