Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in three of five applicable records.
Client #1 was admitted July 16, 2025 and discharged October 22, 2025. A treatment plan was completed on July 16, 2025 and an update was due by September 14, 2025 but not completed until September 18, 2025.
Client #3 was admitted June 4, 2025 and still a current client. A treatment plan was completed on August 4, 2025 and an update was due by October 3, 2025 but not completed until October 8, 2025.
Client #4 was admitted July 3, 2025 and still a current client. A treatment plan was completed on September 1, 2025 and an update was due by October 31, 2025 but not completed until December 28, 2025.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
On March 4,2026 Project manager will retrain counselors on treatment plan compliance and reminders that updates are to be performed every 60 days Project manager will perform a monthly random chart audit to insure all plans are within the compliance time and create a check off list signifying the audit has occurred and sign or initial that all plans are in the 60 day plan range. On weekly census sheets she will remind clinicians to check treatment plans to insure they comply with regulations.
Non-compliance will be addressed through corrective coaching by project manager |