Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in five of seven applicable records.
Client #1 was admitted on July 29, 2024 to the outpatient level of care and was active at the time of review. A treatment plan was completed on August 12, 2024. The next update was due no later than October 12, 2024; however, it was completed on October 14, 2024.
Client #3 was admitted on June 4, 2024 to the outpatient level of care and was active at the time of review. A treatment plan was completed on August 19, 2024. The next update was due no later than October 19, 2024; however, it was completed on October 22, 2024.
Client #5 was admitted on January 17, 2023 to the outpatient level of care and was discharged October 27, 2024. A treatment plan was completed on July 23, 2024. The next update was due no later than September 23, 2024; however, it was completed on September 30, 2024.
Client #6 was admitted on December 13, 2023 to the outpatient level of care and was discharged June 3, 2024. A treatment plan was completed on February 19, 2024. The next update was due no later than April 19, 2024; however, no update was completed.
Client #7 was admitted on March 14, 2024 to the outpatient level of care and was discharged August 8, 2024. A treatment plan was completed on April 29, 2024. The next update was due no later than June 29, 2024; however, it was completed on July 10, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/1/2024 the Facility Director shall communicate to all clinical staff the expectation that treatment plans must be done pre-emptively. Treatment plans that are due on a non-service date (holiday or weekend) will be completed the first business day prior to the end date of the treatment plan. Therapist will monitor end dates to ensure completion of treatment plans are done before the end date even if this requires a treatment plan to be completed before the 60-day mark. Clinical supervisor will monitor the efforts of therapist through monthly chart sample audits. |