Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of four applicable records reviewed.
Client #1 was admitted on October 16, 2024, and was still active at the time of the inspection. A treatment plan was completed on November 8, 2024, and the next update was due no later than January 8, 2025; however, there were no additional updates documented in the client record.
Client #4 was admitted on March 15, 2024, and was discharged on October 23, 2024. A treatment plan was completed on July 17, 2024, and the next update was due no later than September 17, 2024; however, there were no additional updates documented in the client record.
Client #5 was admitted on May 10, 2024, and discharged on July 12, 2024. A treatment plan was completed on May 10, 2024, and the next update was due no later than July 10, 2024; however, there were no additional updates documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
L1883: With failing to document treatment plan updates within the regulatory timeframe, the SOS counselor will complete a client file checklist that will be implemented during the client's course of treatment in the SOS program. The client file checklist will focus on treatment plan due dates and updates, handling treatment plans during the event of a medical emergency or vacation with the SOS counselor or in situations where a client has been discharged prematurely. These are a few of the focal points that the client file checklist will focus on. The client file checklist is a method of organization and even structure for the counselor. The Project Director can monitor the ongoing success of the document during supervisions and quarterly file reviews. |