Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days for clients in the outpatient activity in two of three applicable client records reviewed.Client #2 was admitted on November 15, 2022 and was active at the time of inspection. The comprehensive treatment and rehabilitation plan was completed on December 28, 2022 and the first update was due no later than February 8, 2023; however, the update was not completed until March 1, 2023. Client #4 was admitted on July 13, 2022 and was discharged on October 26, 2022. The comprehensive treatment and rehabilitation plan was completed on August 15, 2022 and the first update was due no later than October 15, 2022; however, the update was not completed prior to the client's discharge.This is a repeat citation from the May 16, 2022 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff education will be provided during department staff meeting on 6/9/23 regarding the Treatment plan update policy. Director will provide an overview of the policy for staff, provide a written copy to the staff, and staff will sign off on the education provided once all questions are answered. During this staff meeting and ongoing supervision director will provide tips on tracking treatment plan time frames to ensure compliance. Staff will also be educated on the process of reviewing the treatment plan at the beginning of each session with client to both measure progress on goals and also to ensure that compliance with dates of updates are kept.
In addition, director will conduct ongoing chart audits of each staff members active clients. Director will complete 3 chart audits per week per staff member. Director will complete the paper chart audit form, that will measure multiple compliance areas, but will also have a specific line for treatment plan update time frames. Director will provide the complete paper chart audits to each staff members, with corrections that are to be completed within a certain time frame. Director and staff member will review these in weekly supervision. Director will have responsibility of oversight to ensure audits are completed and this does not reoccur. |