Observations
Based on a review of client records, the facility failed to document a complete client record which included follow-up information in two out of five records reviewed.
The findings include:
Five client records were reviewed on March 18, 2016. The facility failed to document a complete client record which included follow-up information in client record # 2 and 4.
Client # 2 was admitted to the facility on December 11, 2014 and discharged on July 15, 2015. As of the time of inspection, the facility failed to document a complete client record which included follow-up information for client # 2.
Client # 4 was admitted to the facility on November 26, 2013 and discharged on May 11, 2015. As of the time of inspection, the facility failed to document a complete client record which included follow-up information for client # 4.
The findings were reviewed with the facility staff during licensing inspection.
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Plan of Correction
Clinical coordinator will review with D&A therapists during supervision the D&A follow-up requirements, including outreach and documentation of outreach attempts to clients who are discharged from treatment. Additionally, supervision will be used to discuss the referral process for discharged D&A clients, including referral to alternative levels of care and re-entry into outpatient services. Clinical coordinator will audit D&A charts when client is being discharged in order to review successful completion of follow-up requirements and verify that each chart is complete per licensure requirements.
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