Observations
The time period for observation is insufficient to determine compliance as of August 1, 2012. The deficiency from the licensing inspection of January 24, 2012 is as follows:
Based on a review of the facility's policy and procedure manual and client records, the facility failed to document follow-up information in two of two outpatient client records.
The findings include:
Seven outpatient client records were reviewed on January 6, 9 & 24, 2012. Four client records were closed. Two of the closed client records required documentation of a follow-up attempt. Per agency policy, a follow-up will be conducted within six months of discharge. The facility failed to conduct a follow-up within six months of discharge in client record # 10 and 11.
Client # 10 was admitted into treatment on March 9, 2011 and discharged on June 3, 2011. A follow-up attempt was due to be completed no later than December 3, 2011. The facility failed to provide documentation of a follow-up attempt as of January 24, 2012.
Client # 11 was admitted into treatment on March 7, 2011 and discharged on June 10, 2011. A follow-up attempt was due to be completed no later than December 10, 2011. The facility failed to provide documentation of a follow-up attempt as of January 24, 2012.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the December 28, 2010 licensing inspection.
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Plan of Correction
As of 2/6/2012, the admissions staff at all levels of care will complete the consent for follow-up contacts with every patient that is admitted.
Regarding transfers from to any satellite facility, these consents will again be completed upon admission to the satellite, before the hard copy medical record chart arrives at that site, to ensure that a completed consent will be included in each patient's medical record.
With completed consent forms available in each patient's medical record, the staff assigned to make follow-up calls/attempts will be able to do so. These contacts/attempts will be conducted within 6 months of the patient's discharge from the final level of care of the patient's complete treatment event.
On February 6, 2012, the Director of Outpatient Services, reviewed the procedures for follow-up conctacts with the facility's administrative assistant and clinical manager. This review underscored the need for the assigned facility staff to conduct follow-up attempts and complete the required documentation, entering it into the medical record chart.
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