Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days for outpatient clients in three of seven applicable records.
Client #1 was admitted to outpatient on June 30, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on June 30, 2023. A treatment and rehabilitation plan update was due no later than August 30, 2023, but was not completed until October 25, 2023.
Client #6 was admitted to outpatient on July 14, 2023 and discharged on November 1, 2023. A treatment and rehabilitation plan was developed on July 14, 2023. A treatment and rehabilitation plan update was due no later than September 14, 2023, but was not completed until September 26, 2023.
Client #7 was admitted to outpatient on April 7, 2023 and discharged on September 29, 2023. A treatment and rehabilitation plan was developed on April 7, 2023. A treatment and rehabilitation plan update was due no later than June 7, 2023, but was not completed until June 29, 2023.
A treatment and rehabilitation plan was developed on June 29, 2023. A treatment and rehabilitation plan update was due no later than August 29, 2023, but was not completed prior to discharge from the program.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Team Leader will facilitate group staffing/supervision on 2/8/2024 from 1-2pm and will review the SPHS internal policy and DDAP regulatory standards for Treatment Plan updates and related time frames ensuring that treatment plans will be reviewed and updated at a minimum of every 60 days. This re-training will emphasize the importance of treatment plan updates being completed even if the client has not been actively attending their sessions as well as completion at the time of discharge if a treatment plan update is due. A group supervision form will be completed and signed by all clinical staff acknowledging they have been re-trained in this requirement. Clinical staff that are not present for this group staffing will review the information with the Clinical Supervisor or Team Leader at their next scheduled individual supervision and will sign the individual supervision log confirming re-training of this requirement. All clinical staff will be retrained by 3/1/2024 as documented in supervision logs.
At the meeting on 2/8/2024, clinical staff will be given a documentation compliance spreadsheet to assist in tracking regulatory documentation standards inclusive of treatment and rehabilitation plan updates. Clinical staff will complete and maintain this compliance spreadsheet. During regularly scheduled supervision, the compliance spreadsheet will be reviewed by the supervisor or team leader and documented in supervision notes. Any counselors 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 can be made available at the request of DDAP.
Following agency policy, a mock audit will occur in approximately 6 months. This audit will be conducted by another member of the management team and will confirm that treatment plan updates are being completed at a minimum of every 60 days.
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