Observations
Based on a review of client records, the facility failed to have a complete record in five of ten records reviewed.
The findings include:
Ten client records were reviewed on March 19, 2013. Six were reviewed for an aftercare plan, #3, 4, 6, 8, 9 and 10.
Client #3 was admitted on June 25, 2013 and discharged on January 28, 2014. Client #3's aftercare plan was developed on January 28, 2014 and failed to document the client's support services and time frames.
Client #6 was admitted on September 30, 2013 and discharged on January 27, 2014. Client #6's aftercare plan was developed on January 27, 2014 and failed to document the client's goals with no time frames and the person to call if the client would like to return to the facility for treatment.
Client #8 was admitted on November 25, 2013 and discharged on January 16, 2014. Client #8's aftercare plan was developed on January 8, 2014 and failed to document the client's support services and goals with time frames.
Additionally, the facility failed to document follow-up attempts in two records reviewed.
Client #5 was admitted on August 6, 2013 and discharged on February 28, 2014. As of the date of the licensing inspection there was no follow-up documented in client #5's record.
Client #7 was admitted on October 11, 2013 and discharged on December 20, 2014. As of the date of the licensing inspection there was no follow-up documented in client #7's record.
The facility did not dispute the findings.
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Plan of Correction
A training to review discharge process will take place on 4/17/14. This training will include proper documentation of Discharge Aftercare plan Client Support Services and Time Frame and timely follow up calls for discharges. Following this training, Discharge Aftercare plans will be monitored for accurate completion of Client Support Services and Time Frames. All clients will receive a follow up call within 7 days post-discharge. This call will be documented in a clinical progress note. Monitoring for compliance on this deficiency will take place weekly by the Program Coordinator who will review Discharge Aftercare Plans and follow up call progress notes for accurate and timely completion. Should ongoing problems be noted, Program Coordinator will work individually with the staff member who is struggling to assist in bringing him/her into compliance. |