Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in three out of three applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed 7 days following discharge for clients with an outside referral.Client #5 was admitted on March 7, 2025 and discharged on June 6, 2025. A follow up was due no later than June 13, 2025; however, it was not completed until June 16, 2025.Client #6 was admitted on January 30, 2025 and discharged on May 28, 2025. A follow up was due no later than June 6, 2025; however, it was not completed until June 9, 2025. Client #7 was admitted on January 15, 2025 and was discharged on June 4, 2025. A follow up was due no later than June 11, 2025; however, it was not completed until June 25, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The time frame for client follow-up will be changed from 7 days to 30 days following discharge. This will allow for sufficient time for the client to attend the scheduled aftercare appointments and for the client to successfully transition to the discharge resource prior to the follow-up contact.
This change has been reflected on the standard discharge paperwork that is located in the clinical record.
Adherence to this policy will be supervised by the Clinical Director. |