Observations
Based on a review of client records, the facility failed to document a complete client record which included a record of services provided in two out of nine records reviewed.
The findings include:
Nine client records were reviewed on November 12, 2015, to ensure that the facility documented a complete client record which included a record of services provided. The facility failed to document a record of services provided in client records, # 4 and 5.
Client # 4 was admitted to the facility on October 13, 2015. The facility failed to document a complete client record which included a record of services provided for client # 4, as of the date of the licensing inspection.
Client # 5 was admitted to the facility on August 21, 2015. The facility failed to document a complete client record which included a record of services provided for client # 5, as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All counselors will submit all record of service to the Clinical Supervisor by the end of the month to ensure accurate recording of services. On a quarterly basis Program Director will review all closed out and active charts to ensure chart compliancy. |