Observations
Based on the review of client records, the facility failed to document case consultation notes in one of two client records.
Findings:
Ten client records were reviewed on December 19, 2008 and January 13, 2009. Six were reviewed as outpatient client records. Two client records were required to have case consultation notes. The facility did not document required case consultation notes in client record # 10.
In client record #10, the case consultation due in July, 2008 was not completed until September, 2008. The case consultation note due in December 2008, was not documented.
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Plan of Correction
- On 01/22/2009, in a staff meeting, the facility's Clinical Manager reviewed the respective regulatory standard with the treatment team. It was specified that for outpatient cases, case consultations must occur on each case within 90 days of admission and, thereafter, within 90 days of each completed case consultation.
- The Clinical Manager will maintain a tickler file system that will alert her and the clinical staff when Case consultations are next due.
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