Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of four applicable records.
Client #6 was admitted to the outpatient level of care on August 21, 2024 and was discharged January 17, 2025. Client #6 ' s record contained a treatment plan dated September 24, 2024. A treatment plan update was due no later than November 24, 2024. No further treatment plan updates were completed prior to Client #6 ' s discharge.
Client #7 was admitted to the outpatient level of care on October 16, 2024 and was discharged February 21, 2025. Client #7 ' s record contained a treatment plan dated November 1, 2024. A treatment plan update was due no later than January 1, 2025. No further treatment plan updates were completed prior to Client #7 ' s discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Clinical Manager will review these findings with the therapist and re-educate the therapist on the process to complete treatment plans within the electronic health record as well as the timeline for due dates of treatment plan updates.
The Regional Clinical Manager will audit a minimum of 25% of the patient charts for the therapist over the next 6 months to ensure compliance. |