Observations
Based on a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in three client records reviewed.
Client #1 was admitted on December 14, 2020 and was still active at the time of the inspection. A treatment plan update was completed on December 28, 2020 and the next update was due no later than February 28, 2021; however, there was no update documented until April 14, 2021.
Client #2 was admitted on May 6, 2021 and was still active at the time of the inspection. A treatment plan update was completed on January 4, 2021 and the next update was due no later than March 4, 2021; however, there was no update documented until May 11, 2021.
Client #4 was admitted on September 3, 2020 and was still active at the time of the inspection. A treatment plan update was completed on November 23, 2020 and the next update was due no later than January 23, 2020; however, there was no update documented until April 1, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
An in service meeting was held on May 28, 2021 to address clinical staff on treatment management procedures specific to the treatment plan update process. All staff will be directed to update treatment plans every 60 days or sooner. Should the client fail to attend the scheduled session to develop treatment plans as due, clinical staff will proceed and document that the plan will be reviewed with the client during the next attended session. The Clinical Supervisor will review treatment plans for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions. |