Observations
Based on a review of client records, the facility failed to provide a complete client record on each individual in three of four client records reviewed.
The findings include:
Four client records were reviewed on February 20, 2014. Three of the four client records did not contain all of the required documentation, client records #2, 3 and 4.
Client #2 was admitted to outpatient treatment on December 17, 2013. The facility did not document medication records which indicate the name of the drug, dosage, and frequency of use in client record #2. One medication which was documented in the client record was not on the medication record. Other medications were documented but did not indicate the dosage and frequency of use.
Client #3 was admitted to outpatient treatment on August 23, 2013 and discharged on October 10, 2013. Documentation of a follow up attempt was to be completed by January 10, 2014, and was not documented as of February 20, 2014.
Client #4 was admitted to outpatient treatment on September 5, 2013 and discharged on November 11, 2013. Documentation of a follow up attempt was to be completed by February 11, 2014, and was not documented as of February 20, 2014.
The findings were reviewed with the director and were not disputed.
|
Plan of Correction
By March 15, 2014 the following changes will be fully implemented by and followed up on by the Facility Director:
1. All staff will be re-educated on the need for complete medical information to be completed in each chart. This is to include not only the type of medication, but the dosage as well. This will be more thoroughly reviewed during regular case supervision.
2. The computerized system used to print out the follow-up survey letters has been modified to automatically print and save to a designated folder on the network a list of all clients to whom a Follow-Up survey is being sent on any given date. This saved list will include client name, client ID, the assigned worker and the date that the list was printed / surveys were sent out. |