Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans within 60 days in three of seven records.
Client #2 was admitted on November 26, 2024 and discharged on August 20, 2025. A treatment plan was completed on June 9, 2025 and an update was due by August 8, 2025 but not completed until August 13, 2025.
Client #4 was admitted on January 3, 2025 and discharged on July 25, 2025. A treatment plan was completed on January 3, 2025 and an update was due by March 4, 2025 but not completed until March 14, 2025. Another treatment plan update was due by May 13, 2025 but not completed until May 23, 2025.
Client #7 was admitted on November 13, 2024 and discharged on May 16, 2025. A treatment plan was completed on February 21, 2025 and an update was due by April 22, 2025 but not completed prior to the client's discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Treatment Plans updates will be completed and documented within required timeframes.
The Clinical Director will review policies and expectations with all staff regarding treatment plan time frames by 9/19/25.
Staff will utilize the treatment plan tracker tool in our EHR to conduct weekly checks to ensure that all treatment plans are completed within required time frames. The Clinical Director will send treatment plan reports weekly to all clinicians as a reminder. If a Clinician is out of compliance this will be discussed in a documented clinical supervision session, and a Performance Improvement Plan will be initiated. Progress will be monitored via monthly chart reviews. The Clinical Director will review progress during monthly supervision sessions. Any required corrections will be completed within 72 hours. |