Observations
Based on applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in four of six records.
Client #1 was admitted on October 2, 2024 and was discharged on December 23, 2024. A treatment and rehabilitation plan was developed on October 21, 2024. A treatment and rehabilitation plan update was due no later than December 21, 2024, but was not completed prior to discharge.
Client #3 was admitted on September 27, 2024 and was discharged on March 26, 2025. A treatment and rehabilitation plan update was completed on December 9, 2024. The next treatment and rehabilitation plan update was due no later than February 9, 2025, but was not completed until February 13, 2025.
Client #4 was admitted on December 6, 2024 and was discharged on June 6, 2025. A treatment and rehabilitation plan was developed on December 18, 2024. A treatment and rehabilitation plan update was due no later than February 18, 2025, but was not completed until February 26, 2025.
Client #6 was admitted on December 20, 2024 and was discharged on August 15, 2025. A treatment and rehabilitation plan was developed on January 15, 2025. A treatment and rehabilitation plan update was due no later than March 17, 2025, but was not completed until August 15, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will develop a new self-audit form specifically for the D&A Therapists. This form will include due dates for treatment plans to help ensure timely updates. Therapists are expected to meet with their clients one week before the 60-day update is due to complete the necessary revisions. Once updated, the treatment plan will be submitted for signatures so that it becomes active by the 60th day.
To keep everything on track, the Clinical Supervisor will monitor the due dates for these plans and send email reminders to therapists about upcoming deadlines. Staff will be trained on the new process, and this plan of correction is scheduled to take effect starting September 8, 2025.
Additionally, the Clinical Director will meet with the Clinical Supervisor at least twice a month. During these meetings, part of the supervision will focus on reviewing the timelines for treatment plans to ensure compliance. Progressive discipline will be applied to anyone who fails to meet the requirements outlined in this plan of correction.
Clinical Director will have direct oversight of the POC.
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