Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans within 60 days in three of seven applicable client records.
Client #2 was admitted on January 3, 2023 and discharged on June 28, 2023. A treatment plan was completed on March 15, 2023 and an update was due by May 15, 2023 but not completed until June 9, 2023.
Client #5 was admitted on April 26, 2023 and still a current client at the time of the inspection. A treatment plan was completed on June 29, 2023 and an update was due by August 28, 2023 but there was no further treatment plan updates at the time of the inspection.
Client #7 was admitted on June 1, 2023 and still a client at the time of inspection. A treatment plan was completed on June 28, 2023 and an update was due by August 28, 2023 but there was no further treatment plan updates at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 12, 2022 annual licensing inspection.
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Plan of Correction
Clinical Supervisor will review expectations of clinical documentation and timelines for paperwork completion in Group/Individual supervision by 11/27/2023.
The clinical forms audit and treatment plan analysis report in the agency EHR will be reviewed in group and individual supervision to alert clinicians of upcoming treatment plans that need completed.
Progress will be monitored by monthly chart audits and reviewed with Clinicians monthly. Quarterly chart audits will also be conducted by CQI Manager to assist in maintaining compliance with timely submission of required documentation. |