Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in one of two applicable client records reviewed. Client #4 was admitted May 26, 2021 and was discharged August 9, 2021. There was no follow-up information documented in the record as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Regional Quality Manager will be responsible for completing monthly chart audits for each clinician to ensure all discharge documentation, including 7 day follow up calls, are completed and timely. Clinical Supervisor will review results of audits with clinicians in group and/or individual supervision sessions. |