Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three of five applicable records.
Client #2 was admitted to the outpatient level of care on May 4, 2023 and was active at the time of review. A treatment plan was completed on June 5, 2023 and the next update was due no later than August 5, 2023. The next treatment plan update was documented as completed on August 24, 2023.
Client #3 was admitted to the outpatient level of care on March 24, 2023 and was active at the time of review. A treatment plan was completed on April 18, 2023 and the next update was due no later than June 18, 2023. The next treatment plan update was documented as completed on June 23, 2023. The next treatment plan update was due no later than August 23, 2023; however, the next treatment plan update was documented as completed on September 7, 2023.
Client #4 was admitted to the outpatient level of care on November 3, 2022 and was discharged April 3, 2023. A treatment plan was completed on January 11, 2023 and the next update was due no later than March 11, 2023. There were further documented treatment plan updates in the client record.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 11, 2022 annual licensing renewal inspection.
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Plan of Correction
By 10/23/23 the Executive Regional Director of Outpatient Services will meet with the individual clinician that did not comply with this requirement and review this standard, applicable policy and procedure, EHR ? Credible Treatment Plan Update Review Report, and audit. This reminder included the Master Treatment Plan need updated on or before due date even when client has not been attending sessions.
The Executive Regional Director of Outpatient Services shall review this standard and applicable policy and procedure during Clinical Supervision on 11/1/2023 as well and share techniques for maintaining compliance with documentation requirements as related to Treatment Plan compliance.
The Regional Director of Health Information Management shall pull the Treatment Plan Update Review Report weekly and audit all charts that hit this report to ensure the Treatment Plan was completed timely by the Date Next Plan Review is Due for 3 months.
The Regional Director will share the results of the weekly Treatment Plan Update Audit with the Executive Regional Director of Outpatient Services, the Vice President of Clinical Services weekly , and the Audit & Peer Review Committee monthly.
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