Observations
The facility failed to ensure that all client records were complete.
During an onsite complaint investigated conducted on August 24, 2021, the complainant record was reviewed. Client #1 was admitted on 3/17/2021 and discharged on 4/22/2021. The client record did not include a discharge summary. This was discussed with facility staff during this visit.
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Plan of Correction
Division Director instructed counselor to complete Discharge Summary for client #1 by 8/30/2021.
Division Director reviewed the completed document in the electronic health record on 8/31/2021 and confirmed its' completion on 8/30/2021.
Clinical Supervisor will review discharge summary regulations and compliance during clinical meeting on Friday, September 3rd, 2021 and will maintain document that supports the review of discharge summaries needing to be completed within 7 days of discharge.
Ongoing, Clinical Supervisor will audit closed charts on a monthly basis (2 per counselor) to ensure compliance. Concerns or issues will be addressed during individual supervision with the counselor and documented. |