Observations
Based on a review of client records, the facility failed to document a family medical history five of ten client records reviewed.
The findings include:
Ten client records which required documentation of a family medical history were reviewed on February 26, 2014. The facility failed to document the family medical history in client records # 1, 3, 7, 8 and 9.
Client # 1 was admitted on 8/29/13 and discharged on 10/29/13. The facility failed to document a family medical history for this client.
Client # 3 was admitted on 3/20/13 and discharged on 10/28/13. The facility failed to document a family medical history for this client.
Client # 7 was admitted on 12/11/13 and discharged on 2/17/14. The facility failed to document a family medical history for this client.
Client # 8 was admitted on 10/23/13 and was still an active client at the time of the inspection. The facility failed to document a family medical history for this client as of Feb. 26, 2014.
Client # 9 was admitted on 11/4/13 and was still an active client at the time of the inspection. The facility failed to document a family medical history for this client as of Feb. 26, 2014.
The project director confirmed the findings.
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Plan of Correction
Following licensure visit on February 26, Clinical Supervisor discussed with counselors need to document family medical history and not leave blank if no history reported. Counselors will document all reported family medical history and if none is reported draw lines through family medical history. Counselors were directed by Clinical Supervisor to review all their current active client files and if needed to discuss and complete at next client session the family medical history. Beginning March 3 during initial client file review for new clients or at 60 day treatment update for current active clients, Clinical Supervisor will review that family medical history is documented. All active client files will have family medical history documented by March 31, 2014.
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