Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of four records reviewed.Client #2 was admitted on March 23, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 1, 2024 and an update was due no later than June 1, 2024; however, it was not completed until June 3, 2024. Client #6 was admitted on September 12, 2023 and was discharged on January 4, 2024. A comprehensive treatment plan was completed on September 14, 2023 and an update was due no later than November 14, 2023; however, it was not completed until November 22, 2023.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Regional Quality Manger (RQM) will continue to monitor charts for required documentation monthly. Staff members will utilize case trackers that identify due dates and this will be reviewed monthly with Clinical Supervisor during monthly supervision. Clinical Supervisor will review notes, treatment plan updates, etc. prior to monthly supervision to ensure treatment plans are regularly reviewed and updated during scheduled individual sessions. Progress will be reviewed with RQM and Executive Director monthly. Deficiencies will be addressed in weekly staff meeting and during monthly individual and group supervision. |