Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in three of seven client records reviewed.
Client # 1 was admitted on April 20, 2022 and was still active at the time of inspection. The individual treatment plan was completed on May 5, 2022, and the first update was due no later than July 5, 2022; however, the update was completed on August 13, 2022.
Client #3 was admitted on May 5, 2022 and was still active at the time of inspection. A treatment plan update was completed on June 12, 2022, and the next update was due no later than August 12, 2022; however, the update was completed on September 15, 2022.
Client #6 was admitted on August 11, 2022 and was discharged on December 5, 2022. A treatment plan update was completed on September 19, 2022, and the next update was due no later than November 12, 2022; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Outpatient Program will re-educate and re-train all clinical staff to fully complete all treatment plans, initial and updates as per policy and state standards by 2/28/2023. Training was initiated on 2/21/23 by The Director of Outpatient Services to all clinical staff on the proper completion of all treatment plans as detailed in facility policy. Any clinical staff member that is not able to attend the scheduled trainings will do so on or before 3/7/2023 or thereafter before their next worked shift to assure understanding Ongoing, Director of Outpatient Program will monitor through monthly audits of charts ensuring the compliance for treatment plans, initial and updates are being fully filled out per facility policy and standards. Compliance of the audits will be reported monthly while reviewing a sample of 20 closed and open chart audits within the Performance Improvement Committee. |