Observations
The facility failed to document a complete client record in four of seven client records reviewed during the annual licensing inspection conducted on April 26, 2017.
Client # 4 was admitted on February 28, 2017 and discharged on March 21, 2017. The client record did not include the following documentation: record of services, progress notes, case consultation and discharge summary.
Client # 5 was admitted on December 27, 2016 and discharged on January 17, 2017. No record of services was documented.
Client # 6 was admitted on December 27, 2016 and discharged on January 14, 2017. The client record did not include the following documentation: record of services and follow-up information.
Client # 7 was admitted on January 13, 2017 and discharged on January 29, 2017. No follow-up information was documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) All staff responsible for documenting in the clinical record will receive training on proper completion of the record of services, progress notes, case consultations, discharge summaries and follow up. Training will be provided by the Clinical Director and QI Coordinator and will be completed within 30 days.
2) QI Coordinator will conduct weekly chart audits to ensure compliance.
3) Clinical Director will provide supervision on any deficiencies noted in the weekly chart audits.
4) QI Coordinator will conduct monthly audits on a representative sample of charts for each month to ensure compliance and will notify Clinical Director of any ongoing deficiencies to be addressed in clinical supervision. |