Observations
Based on a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in five of five applicable client records reviewed.
Client #1 was admitted on February 10, 2022 and was still active at the time of the inspection. A treatment plan update was completed on March 10, 2022, and the next update was due no later than May 10, 2022; however, there was no update documented in the record until May 18, 2022.
Client #2 was admitted on March 2, 2022 and was still active at the time of the inspection. A treatment plan update was completed on March 28, 2022, and the next update was due no later than May 28, 2022; however, there was no update documented in the record until June 6, 2022.
Client #4 was admitted on February 9, 2022 and was still active at the time of the inspection. A treatment plan update was completed on May 9, 2022, and the next update was due no later than July 9, 2022; however, there was no update documented in the record until July 19, 2022.
Client #5 was admitted on January 26, 2022 and was discharged on August 29, 2022. A treatment plan update was completed on March 1, 2022, and the next update was due no later than May 1, 2022; however, there was no update documented in the record until May 24, 2022.
Client #7 was admitted on December 8, 2021 and was discharged on September 27, 2022. A treatment plan update was completed on June 21, 2022, and the next update was due no later than August 21, 2022; however, there was no update documented in the record at the time of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Genesis House, Inc. failed to document treatment plan updates within the regulatory timeframe.
Genesis House, Inc. will train/retrain all new and existing clinical employees on the importance of, and regulatory expectations of treatment plan updates on or before 60 days of the initial treatment plan.
All clinical supervisors will monitor treatment plan update timelines using a clinical documentation tool. This tool will provide clinical staff the needed information to maintain documentation compliance.
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Observations
Based on a review of seven outpatient client records, the facility failed to document and compete follow up information in one of three applicable client records reviewed.
Client #3 was admitted on January 26, 2022 and was discharged on July 25, 2022. There was no documentation of follow up information being completed in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 27, 2021 licensing inspection.
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Plan of Correction
Genesis House, Inc. failed to document post discharge follow up within the regulatory timeframe.
Genesis House, Inc. will train/retrain all new and existing clinical employees on the importance of, and regulatory expectations of post discharge follow up.
All clinical supervisors will monitor post discharge follow up timelines using a clinical documentation audit tool. This tool will provide clinical staff the needed information to maintain documentation compliance. |