Observations
Based on a review of client records, the facility failed to document case consultations as per facility policy in two of four client records.
The findings include:
Four active client records were reviewed on August 22, 2012. Case consultations were required to be completed in all four active client records. Per facility policy, Case consultations for outpatient clients are to be completed in the first thirty days of treatment and then every sixty days thereafter. Case consultations were not completed as required by facility policy in client records # 1 and 3.
Client #1 was admitted on May 24, 2012. A case consultation was due to be completed by June 24, 2012. A case consultation was not completed until June 29, 2012.
Client # 3 was admitted on April 18, 2012. A case consultation was due to be completed by May 18, 2012. A case consultation was not completed until June 1, 2012.
An interview with the clinical supervisor took place on August 22, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
Program Director will review agency policy and procedures pertaining to case consultations with all clinical staff.
Program Director will review case consultation process weekly with clinical staff and monitor progress through the monthly QI/UR process. |