Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes a record of service for sessions provided to the client in five of ten client records reviewed.
The findings include:
Ten client records requiring a complete client record on an individual were reviewed on July 15, 2015. The facility did not provide a complete client record for client's, #2, 5, 6, 7 and 10.
Client #2 was admitted into treatment on June 3, 2015 and was still active at the time of the on-site inspection. The facility failed to include documentation of a record of service in the client record as of the date of the inspection.
Client #5 was admitted into treatment on August 1, 2014 and was discharged on December 17, 2014. The facility included a record of service for the client in the client record; however, there was only one entry on the record of service for individual sessions and there were a total of 23 individual session progress notes documented in the client record during the client's treatment. Therefore, the record of service was incomplete at the time of the inspection.
Client #6 was admitted into treatment on January 8, 2015 and was discharged on May 8, 2015. The facility failed to include documentation of a record of service in the client record as of the date of the inspection.
Client #7 was admitted into treatment on July 21, 2014 and was discharged on March 23, 2015. The facility failed to include documentation of a record of service in the client record as of the date of the inspection.
Client #10 was admitted into treatment on September 26, 2014 and was discharged on February 13, 2015. The facility included a record of service for the client in the client record; however, the record of service only reflected services provided during the month of January 2015 and did not include any other month of the client's treatment. Therefore, the record of service was incomplete at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Saint John Vianney Center has
implemented a corrective action plan to immediately address this deficiency and to also ensure future compliance.
1) As of 7/31/2015, Record of Service forms for current and discharged residents will be printed by the
Business Office Manager and included in all client records identified as
deficient on the day of inspection.
2) For those currently receiving drug and/or alcohol treatment, client charts will be audited monthly by the Director of MIS, Quality & Regulatory Compliance to ensure a complete Record of Service is present.
3) The results of this monthly audit will be reported to the facility?s Performance Management Committee. Auditing will cease once the client
charts have a compliance rate of 90% or better for six consecutive months.
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