Observations
Based on a review of client records on January 20, 2017, the facility failed to document a treatment plan update at least every 60 days in client records, #1, 4 and 5.
Client #1 was admitted on October 31, 2016 and still active at the time of the inspection. The comprehensive treatment plan was completed on November 14, 2016. The treatment plan update was due no later than January 14, 2017.
Client #4 was admitted on August 22, 2016 and still active at the time of the inspection. The comprehensive treatment plan was completed on September 20, 2016. The treatment plan update was due no later than November 20, 2016.
Client #5 was admitted on July 8, 2016 and still active at the time of the inspection. The comprehensive treatment plan was completed on July 22, 2016. The treatment plan update was due no later than September 22, 2016.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program director met with clinical supervisor to review the charts and policy on 1/23/17. Clinical supervisor retrained staff on 1/25/17.Counselors will go back and update charts that were not in compliance by 3/1/17. Clinical supervisor will audit 5 charts weekly for each counselor for 6 months consistently to ensure compliance to end on 7/26/17, and monthly audits to then resume. |