Observations
Based on a review of seven client records on August 10, 2021, the facility failed to document treatment plan updates within the regulatory timeframe in seven out of seven client records reviewed.
Client #1 was admitted on April 6, 2021 and was still active at the time of the inspection. A treatment plan update was completed on April 23, 2021 and the next update was due no later than June 22, 2021; however, was not completed until July 23, 2021.
Client #2 was admitted on April 7, 2021 and was still active at the time of the inspection. A treatment plan was completed on April 7, 2021 and the next update was due no later than June 6, 2021; however, was not completed until July 7, 2021.
Client #3 was admitted on April 9, 2021 and was still active at the time of the inspection. A treatment plan update was completed April 14, 2021, and the next update was due no later than June 13, 2021; however, the next update not completed until July 21, 2021.
Client #4 was admitted on April 19, 2021 and was still active at the time of the inspection. A treatment plan was completed on April 19, 2021, and the next update was due no later than June 18, 2021; however, the next update was not completed until July 20, 2021.
Client #5 was admitted on March 22, 2021 and was discharged July 1, 2021. A treatment plan update was completed on March 31, 2021 and the next update was due no later than May 30, 2021; however, the next update was not completed until June 22, 2021.
Client #6 was admitted on April 21, 2021 and was discharged on July 15, 2021. A treatment plan update was completed on April 23, 2021, and the next update was due no later than June 22, 2021; however, there were no further treatment plan updates documented in the client record.
Client #7 was admitted on May 11, 2021 and was discharged on July 14, 2021. A treatment plan was completed on May 11, 2021, and the next update was due no later than July 10, 2021; however, there were no further treatment plan updates documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from a licensing inspection that took place on April 22, 2021.
|
Plan of Correction
In a Clinical Team Meeting on 8/31/21, Clinical Director met with Clinicians and reviewed 709.92(b), indicating treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. Clinical Director reviewed the role treatment plans play in the rehabilitation process and the importance of doing reviews every 60 days. Clinical Director reviewed how to perform treatment plan review in EHR and issued a plan for auditing 3 charts randomly on a weekly basis, reviewing TX plan creations and reviews for compliance. |
Observations
Based on a review of seven client records on August 10, 2021, the facility failed to include case consultation notes in two out of six applicable records reviewed.
Client #5 was admitted on March 22, 2021 and was discharged on July 1, 2021. There was no documentation of case consultation notes in the client record.
Client #7 was admitted on May 11, 2021 and was discharged on July 14, 2021. There was no documentation of case consultation notes in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Director met with entire Clinical Team on 8/31/21 and reviewed 709.93(a)(8) regarding Case Consultation notes. Clinical Director reviewed with Clinicians the role of Case Consultations in the treatment process and the fact that we as a team meeting weekly on Thursdays to do consultations, in addition to discussing cases in supervision sessions. Issued a plan for performing random chart audits 3x week, to be performed by the Clinical Director where charts will be pulled and reviewed for inclusion of a Case Consultation note. |