Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in three of seven records.
Client #1 was admitted July 8, 2025 and discharged January 12, 2026. A treatment plan was completed on September 15, 2025 and an update was due by November 14, 2025 but not completed until November 24, 2025.
Client #2 was admitted August 7, 2025 and still a current client. A treatment plan was completed on August 7, 2025 and an update was due by October 6, 2025 but not completed until October 14, 2025. Another update was due by December 13, 2025 but not completed until December 23, 2025.
Client #3 was admitted August 26, 2025 and discharged November 7, 2025. A treatment plan was completed on August 26, 2025 and an update was due by October 25, 2025 but not completed until November 7, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
In response to the citation #1, referencing 709.92 (b) Treatment and Rehabilitation Services, Program Director and Clinical Supervisor reviewed the charts referencing Clients #1, #2 and #3 which were noted by the Licensing Representative as being deficient in that the facility failed to document treatment plan updates every 60 days. Program Director and Clinical Supervisor identified internal monitoring tools available to ensure that staff are aware of the standards for completion of treatment plan updates occurring at least every 60 days. All staff have access to reports contained within our EMR Credible to ensure timely documentation of treatment plan updates. Program Director and Clinical Supervisor met with clinical team at the next weekly staff meeting 3/3/2026 and reviewed citation, standards and timeframes for treatment plan updates and provide refresher training on how to access reports via EMR. Weekly staff meetings will continue to include timeframes specified for case consultation and review of treatment progress and plan updates. Individual staff supervisions, which occur at minimum of once per month, will include review of EMR reports to ensure consistent and timely completion of treatment plan updates. This facility is in full compliance with this standard as of 3/3/2026. |