Observations
Based on a review of outpatient client records, the facility failed to provide a complete client record, which is to include follow-up information within sixty days of discharge, as per the facility's policy, in one of three applicable client record.
Client #6 was admitted on June 14, 2023, and was discharged on November 27, 2023. There was no documentation of a follow-up contact in this client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all requirements regarding maintaining a complete client record on an individual and specifically including required follow up.
In this particular situation our policy indicated that we would follow up on the client sixty days post discharge. Our internal tracking system incorrectly identified the clients discharge date as being 30 days later then it actually was. As such our follow up was scheduled to occur 30 days late.
This reporting error in our EHR has now been identified and addressed. Clinical supervisors, office managers and records clerks have all been reminded of the importance of follow up, made aware of the reporting error and retrained on the requirements. We are confident that this issue has been resolved. The Director will follow up quarterly to ensure continued compliance.
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