Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of three applicable records reviewed. The facility's policy is to initiate a follow-up contact within sixty days for all successfully discharged clients.
Client #7 was admitted on August 1, 2024, and was discharged on November 7, 2024. A follow-up contact was due no later than January 7, 2025; however, there was no documentation of a follow-up in the client record.
This finding was 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 we had a filing and tracking issue resulting in this item being missed. We've identified the issue and assigned back up staff to the follow up process to assist in monitoring, completing, and properly filing follow up/aftercare forms.
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. Our compliance team will also assist in auditing this while conducting file reviews. We are confident that this issue has been resolved. The Director will follow up quarterly to ensure continued compliance.
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