Observations
Based on a review of a client chart during a complaint investigation conducted on 1/19/2023, the facility failed to ensure that the client record was complete.
Client #1 was admitted to outpatient treatment services on 8/15/2022 and discharged on 11/1/2022. The discharge summary describing the reasons for treatment, services offered, response to treatment and client's status or condition upon discharge was not included in the client's record.
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Plan of Correction
As part of a previous plan of correction to address 7-day outreach calls, checking discharge bundles will be added to that plan. Beginning on 1/30/23, Executive Director will run the discharge from the previous week. This list will be sent to the Administrative Assistant to complete outreach calls. A column will be added to that sheet to audit for appropriate discharge paperwork for each of the discharged clients. Administrative Assistant will be trained by Executive Director and Clinical Supervisor on what paperwork is required for each discharge type. Any deficiencies identified will be sent to Executive Director and Clinical Supervisor and responsible staff will be given 24 hours to complete the discharge summary or any additional paperwork. This report will be run weekly by the Executive Director for the prior week's discharge. |