Observations
Based on the review of patient records, the facility failed to document a case consultation which included a disposition in four of five patient records.
The findings include:
Twenty eight patient records were reviewed on August 29- September 1, 2011. Eleven patient records required case consultation notes. Of the eleven patient records, five required an annual case consultation note. Per regulation, the case consultation notes should include, names of persons attending and their disciplines, name of client reviewed, summary and disposition of cases reviewed. The facility did not document a disposition of the cases reviewed in the annual case consultation notes for patient records # 1, 4, 7 and 8.
An interview with the facility director on August 31, 2011, confirmed the annual case consultation notes did not include a disposition.
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Plan of Correction
Re-training of clinical staff addressing the disposition on the Annual Case Consultation was completed during the weekly clinical staff meeting on 9/6/2011. All annual consulatations will be reviewed during these weekly meetings to ensure compliance. In addition, consultations will be reveiwed for compliance during regular weekly chart reviews. The Clinical Supervisor and Lead Counselors will ensure on-going compliance. |