Observations
Based on a review of client records, and the Discharge Planning and Process policy, the facility failed to follow their policy in one of three records reviewed.
Per the Discharge Planning and Process policy, every client will receive a discharge summary and continuing care plan. If a client insists upon leaving, they will receive a discharge summary and continuing care plan.
Client # 1 was admitted on January 16, 2025, and discharged on January 20, 2025. The discharge summary observed in the chart was dated May 20, 2025.
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Plan of Correction
The Director of Clinical Services re-trained Clinical Staff on the timely completion of chart documentation at their monthly staff meeting on 5/27/2025. The Clinical Director/Lead Counselor will audit the charts on a weekly basis for 3 months to ensure 100% compliance. After the 3 months, compliance will be monitored through monthly chart audits. The Clinical staff signed attestation forms acknowledging the education/training they received on this issue. |