Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in two of five applicable records.
Client #2 was admitted on December 4, 2024 and was discharged on February 20, 2025. A treatment and rehabilitation plan was developed on December 4, 2024. A treatment and rehabilitation plan update was due no later than February 4, 2025, but was not completed prior to discharge.
Client #5 was admitted on October 15, 2024 and was discharged on January 24, 2025. A treatment and rehabilitation plan was developed on October 15, 2024. A treatment and rehabilitation plan update was due no later than December 15, 2024, 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
As of June 23, 2025, all clinical staff have been reminded of the 60-day requirement for treatment plan reviews and updates through internal staffing and supervision. While both clients cited in the deficiency are no longer active, the Clinical Director has reviewed all other current client charts to ensure compliance. All open records are currently compliant. All newly hired counselors will receive training on documentation standards, including the 60-day treatment plan review requirement, upon hire. The Clinical Director will conduct weekly random audits of client charts to ensure treatment plan reviews are completed within the 60-day timeframe. These audits will be documented and discussed during monthly supervision meetings. The Clinical Director is responsible for overseeing the implementation of this corrective action and for ensuring ongoing compliance. |