Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include an aftercare plan in two out of four applicable records reviewed.
Client #6 was admitted on May 15, 2025 and discharged on June 26, 2025.
Client #8 was admitted on March 3, 2025 and discharged on May 27, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director and Supervisor will train and reeducate the therapists on the form groups in the electronic health record and what information needs completed with discharge by September 1st, 2025.
Director, Supervisor, and Chief Compliance Officer will review the chart upon discharge from the program to assure that proper documentation is completed. Furthermore the Chief Compliance Office will conduct random audits on D&A Discharges to assure that proper documentation is completed. This will occur on a monthly basis. |