Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed 30 days following discharge.
Client #2 was admitted on April 13, 2023 and discharged on August 9, 2023. A follow up was due no later than September 9, 2023; however, none was completed.
Client #3 was admitted on July 17, 2023 and was discharged on September 20, 2023. A follow up was due no later than October 20, 2023; however, none was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all requirements regarding maintaining a complete client record on an individual and specifically including required follow up.
In this particular situation we had a filing and tracking issue due to staff turn over resulting in some of these being missed and others just not being properly filed. We've identified the issue and assigned back up staff to the follow up process to assist in monitoring, completing, and properly filing follow up/aftercare forms.
Clinical supervisors, office managers and records clerks have all been reminded of the importance of follow up, made aware of the reporting error and retrained on the requirements. Our compliance team will also assist in auditing this while conducting file reviews. We are confident that this issue has been resolved. The Director will follow up quarterly to ensure continued compliance.
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