Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in four of seven applicable records.
Client #1 was admitted on November 2, 2020 was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on April 15, 2025. The next treatment and rehabilitation plan update was due no later than June 15, 2025; however, this was not completed until June 17, 2025.
A treatment and rehabilitation plan update was completed on August 12, 2025. The next treatment and rehabilitation plan update was due no later than October 12, 2025; however, this was not completed until October 14, 2025.
Client #3 was admitted on April 24, 2025 was still active at the time of the inspection. A treatment and rehabilitation plan was completed on May 9, 2025. A treatment and rehabilitation plan update was due no later than July 9, 2025; however, this was not completed until July 11, 2025.
Client #4 was admitted on December 30, 2024 was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on April 7, 2025. A treatment and rehabilitation plan update was due no later than June 7, 2025; however, this was not completed until June 13, 2025.
Client #5 was admitted on March 31, 2025 was discharged on August 8, 2025. A treatment and rehabilitation plan update was completed on April 7, 2025. A treatment and rehabilitation plan update was due no later than June 7, 2025; however, this was not completed until June 13, 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Narcotic Treatment Program will review and maintain compliance with state regulation 709.92 (b) regarding treatment plan timing. The Treatment Center's Facility Director and Clinical Supervisor will implement training specific to this concern and conduct an ongoing review of practices to ensure the correct and appropriate completion of all treatment plans, specifically covering meeting the required timing of treatment plan updates. This process will include the implementation of a revised treatment plan training immediately, as well as annual trainings pertaining to the creation and updates of treatment plans. In addition the clinical supervisor will review the content and timing of treatment plans on reviewed cases during the quality review process conducted monthly. All training will be administered by the Facility Director and/or Clinical Supervisor, and quality reviews will be completed during chart reviews by the Clinical Supervisor. Facility Director will review and update treatment planning policies and procedures to assure clear and understandable language describing the process for completing these requirements prior to presenting them in the treatment plan training scheduled for the first quarterly staff development meeting on March 4th, 2026.
All clinical and COE staff members will be required to participate in the updated training on 3/4/26 to review the concerns presented during this audit and provide guidance on the correct completion and timing of treatment plans.
|