Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include case consultations in three out of seven client records reviewed.
Client #1 was admitted on August 16, 2022 and was still active at the time of the inspection. A case consultation was completed on August 16, 2022 and the next one was due no later than November 16, 2022; however, the next one was completed November 22, 2022.
Client #3 was admitted on July 27, 2022 and was still active at the time of the inspection. No case consultations were completed.
Client #5 was admitted on December 7, 2021 and was discharged on July 1, 2022. A case consultation was due no later than March 7, 2022; however, it was completed on June 7, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Weekly group staffing/supervision on February 7, 2023 2pm-3pm will be facilitated by the Clinical Supervisor and will include reviewing SPHS internal policy and DDAP regulatory standards for case consultations ensuring that all Clients have a Case Consultation a minimum of every 60 days. A group supervision form will be completed and signed by all participants acknowledging they have been re-trained in the documentation of Case Consultations. A copy of this document will be sent to the Clinical Director for review and confirmation that re-training occurred. New Kensington employees that are not present, based on their availability in the office, will review the information with team lead/supervisor at next scheduled individual supervision and sign individual supervision form confirming re-training of Case Consultation requirements. A copy of each Supervision Log will be sent to the Clinical Director to confirm training occurred. During individual supervisions, case consultations will be documented by either the clinician and/or the team lead/supervisor at time of supervision. Random Chart Reviews will be conducted throughout the year by members of the Supervisory Team to ensure compliance. These Chart Reviews will be entered into the client chart by the Clinical Supervisor or Delegate. A Mock Audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will confirm that Case Consultations are being entered into the EHR. |