Observations
Based on a review of client records, the facility failed to ensure all treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of three applicable client records reviewed.
Client #1 was admitted on September 15, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 27, 2024 and the first update was due no later than November 27, 2024; however, the update was completed on December 20, 2024.
Client #2 was admitted on August 16, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 21, 2024 and the first update was due no later than October 21, 2024; however, the update was completed on January 8, 2024.
Client #3 was admitted on February 14, 2024 and was discharged on July 5, 2024. The individual treatment and rehabilitation plan was completed on February 15, 2024 and the first update was due no later than April 16, 2024; however, the update was completed on June 20, 2024.
This is a repeat citation from the January 18, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and executive director with the support of regional director will complete monthly chart audits to ensure treatment plans are being completed within policy timeframes. Re-training will occur during group supervision within 30 days, with expectation of full compliance by 4/01/25. |