Observations
Based on a review of client records and an interview with the project director, the facility failed to document follow-up attempts in three of the six required records.
The findings include:
On January 24, 2011, three client records were reviewed for follow-up attempt documentation. The facility failed to document follow up attempts in two of the three required client records reviewed.
The facility policy titled "Protocol for Follow-up Activity" stated: "Follow-up on client treatment progress will be completed on each discharged client using phone calls and mailed follow-up forms upon 3 months, 6 months and 1 year after discharge. Designated staff will make three contact attempts with each client at each designated interval." The policy statement detailed each step involved. In addition the policy covers, Against Medical Advice (AMA), Administrative, and Transfer. "Follow-up on clients who have dropped out of treatment AMA, who have been administratively discharged, or who have been transferred to another facility will be completed within one week of last date of service. Attempt to re-engage the client in the treatment process or whether or not the client followed through with the referral appointment will be documented via a progress note indicating a follow-up contact by the primary counselor."
Client record # 7 failed to include documentation of a follow up attempt. Client # 7 was admitted on 7/8/10 and discharged on 8/30/10 as non-compliant. The follow up attempt was due on 9/6/10.
Client record # 8 failed to include documentation of a follow up attempt. Client #8 was admitted on 2/22/10 and discharged on 5/5/10 as successful. The follow up attempt was due on 8/5/10.
The project director confirmed that the follow up attempts in these client records were not documented at the time of the licensing inspection.
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Plan of Correction
Project director will review facility protocols for conducting both unsuccessful and successful follow up contacts with the clinical staff during the weekly clinical staff meeting on 2/11/11.
Facility director will monitor completion of facility's follow up contacts on a weekly basis beginning 2/18/11 and report any issues noted to the project director for corrective action to ensure consistent compliance. |