Observations
The facility failed to document case consultations according to the facility's written policy and procedure manual reviewed on February 4, 2020. In addition, the facility failed to document follow-up information according to the facility's written policy.The facility's policy manual indicated case consultations would be documented every ninety days after the client is admitted to treatment.Client # 2 was admitted May 30, 2019. No case consultations were documented.Client # 3 was admitted August 19, 2019. No case consultations were documented.Client # 4 was admitted March 7, 2019 and discharged November 8, 2019. Only one case consultation was documented on October 11, 2019.Client # 5 was admitted June 12, 2019 and discharged October 21, 2019. No case consultations were documented.The facility's policy manual indicated follow-up information would be documented within thirty days of the client's discharge from treatment. No follow-up information was documented in the following client records.Client # 5 was admitted June 12, 2019 and discharged October 21, 2019. Client # 6 was admitted April 25, 2019 and discharged June 22, 2019. Client # 7 was admitted April 11, 2019 and discharged November 13, 2019. The findings were reviewed with staff during the licensing process.
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Plan of Correction
In order to correct this problem, we plan to provide additional training to our clinical staff in the following manner: A refresher training will be provided by the Clinical Supervisor to all our clinical staff members during the 3/3/20 clinical staff meeting. This refresher will emphasize that case consultations are to be done every 90 days and are to be documented on case consultation forms within our electronic medical records software. It has recently come to our attention that some of our clinical staff members were not aware that there was a specific form to be used for these case consultations, and although the consultations were being done during our weekly staff meetings according to our policy, they were not being properly documented. The second part of the clinical staff training will highlight our follow-up policy. The Clinical Supervisor will share with all staff the procedure he has developed to ensure that all closed clients receive a follow up call or letter within 30 days of discharge. The forms within our electronic medical records software which are to be used to document the follow-up will be discussed and explained. A written overview of both the case consultation and follow-up policies will be provided to each staff member for their reference and review. A time of questions and answers will be provided in order to clear up any confusion and be sure there is complete understanding by the staff.
Following this training and continuing on an ongoing basis, the Clinical Supervisor will do weekly reviews of the CAM (Client Access Management) Dashboard with the clinical staff members during their supervision time. This Dashboard alerts each counselor to the date of the last case consultation and to the due date of the next consultation for each client on his or her caseload. This dashboard can be sorted by due date, so that it is possible to see what is due each day as the counselor works. Staff members will be directed to consult this Dashboard on a daily basis in order to manage their individual caseload. For those clients who have not been keeping their appointments, follow-up telephone calls will be made in an attempt to re-engage the clients.
Although each counselor is responsible for managing his or her own caseload and so are responsible for making sure case consultations and follow-ups are done in a timely manner for each client, the Clinical Supervisor will be responsible for seeing that all staff are trained in the use of the CAM Dashboard and in our policies and procedures regarding the management of treatment and rehabilitation services. The Clinical Supervisor, Clinical Director and Project Director as a team are responsible to see that case consultations and follow-ups are done according to our policies.
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