Observations
Based on a review of client records, the facility failed to document an aftercare plan in two of four client record.
The findings include:
Eight client records were reviewed on February 27, 2013. Per the facility policy, the counselor and client will complete an aftercare plan prior to discharge for successful completions. An aftercare plan was required in four client records. The facility did not document an aftercare plan in client records #5 and 6.
In client record # 5, the client was admitted on August 1, 2012 and was discharged on October 31, 2013. There was no documentation of an aftercare plan.
In client record #6, the client was admitted on October 17, 2012 and was discharged on February 1, 2013. There was no documentation of an aftercare plan.
This was discussed and confirmed with facility staff on February 27, 2013.
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Plan of Correction
The Clinical Supervisor will meet with all clinical staff during staff meeting and review the procedure for completing the aftercare plan with the client prior to discharge for successful completion of treatment. The office administrator will complete a weekly review of discharge charts to ensure completion of the aftercare plans. |