Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three of seven records reviewed.
Client #3 was admitted on August 3, 2023 and was still active at the time of the inspection. A treatment plan update was completed on September 4, 2023 and the next update was due no later than November 4, 2023; however, no update was completed at the time of the inspection.
Client #4 was admitted on July 7, 2023, and was still active at the time of the inspection. A treatment plan update was completed on December 13, 2023 and the next update was due no later than February 13, 2024; however, no update was completed at the time of the inspection.
Client #7 was admitted on October 3, 2023, and discharged on March 1, 2024. A treatment plan update was completed on October 24, 2023, the next update was due no later than December 24, 2023, however, no update was completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed during our agency staff meeting on May 16, 2024. Individual treatment plan updates will be completed at least every 60 days. To ensure completion of treatment plan updates at least every 60 days the Clinical Director and Project Director will verify completion during monthly staff meetings. The Clinical Supervisor will also review individual counselor's client records on a weekly basis. |