Observations
Based on the review of client records, the facility failed to document case consultations within the regulatory time frame of the facility's policy and procedures manual which is to be completed at case closure in one out of three records applicable client records.
Client #6 was admitted on November 23, 2021 and was discharged on April 28, 2022. A case consultation should have been completed on April 28, 2022; however, there is no documentation of a case consultation in the case record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor has discussed in clinical staff meetings audit issues including the completion of case consults at discharge. A training was specifically given to the counselor who failed to complete the case consultation note and the training was documented in her personnel chart. Ongoing chart auditing will occur by all clinical staff as well as administrative staff to ensure that case consults are completed in conjunction with our policies and procedures. |