Observations
A review of a chart was conducted on September 22, 2017. Based on this review, it was determined that the facility failed to maintain a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include but not be limited to progress notes.
Prior to the client file review, the Facility Administrator explained the circumstances regarding the client's discharge. These events were not documented in the client's chart.
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Plan of Correction
All available documents that had not been filed on the date of the review and were not accessible at that time due to the Primary Therapist being out on maternity leave will be added to the file. In the future, all documentation will be included within the file upon the final discharge chart review prior to being closed out. A new policy was signed by our Executive Director Carol Hertz on November 6, 2017 and was put into effect at TPFO on November 14, 2017 regarding documentation surrounding a clients discharge on . They are given an aftercare packet and are offered to stay at the facility if they do not have a safe place to return to and if they decline this offer, it is noted on the aftercare packet acknowledgement form. Clients are now being given Narcan upon their discharge if they have notified the facility director prior to have a prescription filled for it. All of these items will be reviewed at discharge by either the Clinical Supervisor or Lead Therapist to ensure completion. |