Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in four of six applicable outpatient records.
Client #1 was admitted to outpatient on August 23, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on August 23, 2023. A treatment and rehabilitation plan update was due no later than October 23, 2023, but was not completed until December 4, 2023.
Client #3 was admitted to outpatient on June 6, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on October 11, 2023. A treatment and rehabilitation plan update was due no later than December 11, 2023, but was not completed until January 12, 2024.
Client #4 was admitted to outpatient on April 19, 2023 and was discharged on November 6, 2023. A treatment and rehabilitation plan was developed on July 24, 2023. A treatment and rehabilitation plan update was due no later than September 24, 2023, but was not completed until October 9, 2023.
Client #7 was admitted to outpatient on August 23, 2023 and was discharged on November 9, 2023. A treatment and rehabilitation plan was developed on August 23, 2023. A treatment and rehabilitation plan update was due no later than October 23, 2023, but was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the staff meeting scheduled on 2/14/2024, supervisory team will review with staff the importance of submitting timely Plans of Care within the 60-day time frame to ensure we are meeting DDAP regulatory standards along with the SPHS Policy surrounding submission of services. This review will specifically focus on ensuring that plans of care are completed even when the client is not actively engaging in treatment services and/or preparing for discharge. At this time, clinicians will also be given client trackers that include the needed update dates for Plans of Care to ensure each clinician is tracking their clients' charts. Compliance with this tracker will be monitored and documented during individual supervisions. Staff not in attendance at the 2/14/2024 meeting will review the timeliness of Plan of Care submission as well as the client tracker no later than 3/6/24. Clinicians that are found to be out of compliance with treatment plan updates will be placed on an Individualized Development Plan and/or Action Plan which will be reviewed regularly during supervisions to ensure that goals established in regard to compliance are being met.
Per SPHS Policy, within the next 6 months, a Mock Audit will be performed by another supervisor within the agency. This audit with function as a mock DDAP licensing visit to ensure that all aspects of charts and physical plant are within compliance standards as established by DDAP and SPHS Policy, including Plan of Care updates per every 60 days.
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