Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven client records reviewed.
Client #2 was admitted on July 18, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on July 23, 2022, and the next update was due no later than August 23, 2022; however, one was completed on August 26, 2022.
Client #6 was admitted on May 16, 2022 and discharged on August 15, 2022. An updated treatment plan was completed on June 19, 2022, and the next update was due no later than July 19, 2022; however, one was completed on July 21, 2022.
Client #7 was admitted on April 28, 2022 and was discharged on July 11, 2022. An updated treatment plan was completed on May 21, 2022, and the next update was due no later than June 21, 2022: however, one was completed on June 23, 2022.
This is a repeat citation from the October 7, 2021 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervision sessions will be held with each clinician no later than 10/14/22 to address treatment management procedures specific to the treatment plan update process. All staff will be directed to update treatment plans at least every 30 days.
The Clinical Supervisor and Division Director will review treatment plans for compliance during monthly audits. This will be reviewed with Clinical staff in documented regular supervisory sessions. Any outstanding items will be corrected/completed within 48 hours.
The Quality Assurance department will complete at least quarterly reviews, to include audits of treatment plan updates for completion. Any issues noted in this area will result in the development of a performance improvement plan.
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