Observations
Based on a review of client records, the facility failed to develop a treatment plan with the client in seven of seven records.
Client #1 was admitted on November 13, 2024, and discharged April 30, 2025. A treatment plan was developed on December 20, 2024, and did not indicate it was developed with the client.
Client #2 was admitted on December 2, 2024, and discharged on June 13, 2025. A treatment plan was developed on January 3, 2025, and did not indicate it was developed with the client.
Client #3 was admitted on November 1, 2024, and discharged on June 11, 2025. A treatment plan was developed on December 8, 2024, and did not indicate it was developed with the client.
Client #4 was admitted on December 13, 2024, and discharged on June 6, 2025. A treatment plan was developed on January 16, 2025, and did not indicate it was developed with the client.
Client #5 was admitted on November 12, 2024, and was still active at the time of inspection. A treatment plan was developed on December 19, 2024, and did not indicate it was developed with the client.
Client #6 was admitted on October 24, 2024, and was still active at the time of inspection. A treatment plan was developed on October 30, 2024, and did not indicate it was developed with the client.
Client #7 was admitted on December 6, 2024, and was still active at the time of inspection. A treatment plan was developed on January 27, 2025, and did not indicate it was developed with the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective 8/15/2025, a comprehensive treatment plan will be developed with the client instead of a preliminary treatment plan. The Facility Director will train clinical staff on these changes and will monitor compliance through ongoing chart audits. |