Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of six records reviewed.
Client #1 was admitted on February 1, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on February 22, 2024 and an update was due no later than April 23, 2024; however, it was not completed until April 30, 2024.
Client #4 was admitted on February 12, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on February 22, 2024, and the next update was due no later than April 23, 2024; however, it was not completed until April 29, 2024.
Client #6 was admitted on September 15, 2023 and was discharged on February 29, 2024. A treatment plan update was completed on December 14, 2023 and the next update was due no later than February 14, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 7, 2023 licensing inspection.
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Plan of Correction
In response to the citation concerning 709.92, Treatment and rehabilitation service, treatment and rehabilitation plans shall be reviewed and updated every 60 days; all clinical staff were educated on July 3, 2024 at group supervision about treatment plan requirements during by Clinical Supervisor and Executive Director. In an effort to improve this deficiency in the future, Clinical Supervisor and Executive Director will be updating the case tracker and clinician's schedules with the following information:
- Treatment plan update column will be dated 30 days from last treatment plan update. This will ensure a treatment plan is updated within the 60 day review period per 709.92b. This will also provide the clinical staff a shorter window of time to reschedule the client, should they cancel and/or no show their scheduled treatment plan session, without treatment plan becoming delinquent.
- Clinical supervisor and Executive Director will place note on client's individual appointment on the clinician's schedule, indicating that treatment plan update is due, as a second reminder for the clinician should they not review the case tracker prior to appointment.
Changes to the case tracker were made by Executive Director on 7/03/2024 and plan of correction has been implemented. Clinical Supervisor and Executive Director will ensure case tracker is updated weekly and clinical staff were educated to review the case tracker at the beginning of each shift to ensure treatment plans are completed timely and individual sessions have been scheduled for all clients on their caseload.
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