Observations
Based on the review of client records, the facility failed to document follow-up information in one of two client records.
The findings include:
Ten client records were reviewed on August 8, 2013. Six client records were reviewed as outpatient records. Per agency policy, follow up information on non-referred clients is to be completed within 30 days. Follow up information was not documented in client record # 10.
Client # 10 was admitted on November 26, 2013 and discharged on February 15, 2013. Follow-up was to be completed by March 15, 2013. There was no documentation that follow-up information had been completed.
The Clinical Supervisor was interviewed on August 8, 2013 and confirmed the findings.
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Plan of Correction
Policies: STST IP-150 Follow-Up, STST IP-149 Data Collection System, STST OP-108 Follow-Up, and STST OP-122 Data Collection System have been further modified to state that all discharges will have follow-up communication at the appropriate time intervals, including those clients discharged administratively or against medical advice. The time intervals are 7 days, six months and one year after discharge for inpatients and one month, six months and one year post-discharge for outpatients. |