Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in four of seven records.
Client #3 admitted on July 14, 2025 and still a current client. A treatment plan was completed on September 15, 2025 and the next update was due no later than November 14, 2025; however, the update was completed on November 17, 2025.
Client #4 admitted on June 3, 2025 and still a current client. A treatment plan was completed on August 11, 2025 and the next update was due no later than October 10, 2025; however, the update was completed on October 31, 2025.
Client #5 admitted on May 14, 2025 and still a current client. A treatment plan was completed on September 10, 2025 and the next update was due no later than November 9, 2025; however, the update was completed on November 17, 2025.
Client #7 admitted on September 3, 2025 and still a current client. A treatment plan was completed on August 21, 2025 and the next update was due no later than October 20, 2025; however, the update was completed on October 22, 2025.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the October 16, 2024 annual licensure inspection.
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Plan of Correction
On 12/3/25 Program Director reviewed requirements with outpatient staff to ensure treatment plan reviews are completed at least every 60 days, even if the individual in services is not present.
As of December 2025, the Program Director will monitor this charting element in monthly audits, which are then reported to the Quality Assurance Committee and will be reviewed for future clients. |