Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of seven applicable records.
Client #3 was admitted to the outpatient level of care on January 29, 2025 and was active at the time of review. Client #3's record contained a treatment plan update dated April 21, 2025. The next treatment plan update was due no later than June 21, 2025; however, the next treatment plan update was not completed until June 26, 2025.
Client #4 was admitted to the outpatient level of care on February 3, 2025 and was discharged May 22, 2025. Client #4 ' s record contained a treatment plan update dated March 10, 2025. The next treatment plan update was due no later than May 10, 2025; however, no further treatment plan updates were found in Client #4 ' s record.
Client #7 was admitted to the outpatient level of care on January 22, 2025 and was discharged July 23, 2025. Client #7's record contained a treatment plan update dated May 7, 2025. The next treatment plan update was due no later than July 7, 2025; however, the next treatment plan update was not completed until July 9, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisor will review the current workflow for completing treatment reviews every 60 days. Supervisor will educate staff on completing these reviews early (at least one week ahead of time) to ensure active treatment plans at the outpatient and IOP levels of care by 9/20/25. Twin Lakes will be moving to a new EHR on 9/27/2025. Management is currently in wave 1 of training. Twin Lakes management will develop a new tracking system when treatment plan updates are due, based on the new EHR and educate staff on new process by 10/31/2025. |