Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in one of five client records reviewed.
Client # 3 was admitted on October 24, 2025, and discharged on December 19, 2025. A comprehensive treatment plan was completed on October 27, 2025, and an update was due no later than November 27, 2025; however, there was no update documented in the record at the time of the complaint investigation conducted on January 6, 2026.
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Plan of Correction
Effective 1/30/26, It will be the responsibility of the Counselor to complete a 30-day Treatment Plan Update review 30 days from the date of admission. It will also be the responsibility of the Counselor to place the signed 30-day Treatment Plan Update review directly in the clients chart. It will be the responsibility of the Residential Tech/Night File Clerk to perform a weekly chart audit and advise the Counselor and Facility Director of any missing documents in writing to include the 30-day Treatment Plan update. It will be the responsibility of the Counselor to provide any missing documents within 48 hours from the date of the notification. It will be the responsibility of the Facility Director to follow-up with the Counselor within 24 hours of the notification to provide any assistance needed to ensure the 30-day Treatment Plan update will be placed in the client chart by the 48 hour deadline. |