Observations
Based on a review of client records, the facility failed to ensure that individual treatment plans included type and frequency of treatment and rehabilitation services in five of five applicable records. Client #1 was admitted to the outpatient level of care on October 23, 2025 and was active at the time of review. Client #1 had an individual treatment plan completed on November 13, 2025. No type and frequency of treatment and rehabilitation services were included in the treatment plan.Client #3 was admitted to the outpatient level of care on January 27, 2026 and was active at the time of review. Client #3 had an individual treatment plan completed on January 27, 2026. No type and frequency of treatment and rehabilitation services were included in the treatment plan.Client #5 was admitted to the outpatient level of care on November 5, 2025 and was active at the time of review. Client #5 had an individual treatment plan completed on January 8, 2026. No type and frequency of treatment and rehabilitation services were included in the treatment plan.Client #6 was admitted to the outpatient level of care on January 2, 2026 and was active at the time of review. Client #6 had an individual treatment plan completed on February 6, 2026. No type and frequency of treatment and rehabilitation services were included in the treatment plan.Client #7 was admitted to the outpatient level of care on January 2, 2026 and was active at the time of review. Client #7 had an individual treatment plan completed on January 8, 2026. No type and frequency of treatment and rehabilitation services were included in the treatment plan.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical manager will re-train staff on treatment plan documentation to ensure they are including the date, frequency, modalities.
This will include a visual demonstration of the exact location as to where the documentation was missing and can be found on the plan. It will also reiterate the workflow of when to make sure this is included.
Facility Director will review progress through random audits.
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