Observations
Based on the review of the program's policies and procedures and client records, the facility failed to document follow-up information in two of three closed client records reviewed.
The findings include:
Eight inpatient client records were reviewed on July 1, 2010. Follow-up information was required in three closed client records, specifically client records # 6, 7, and 8. Per the facilities policy and procedure, follow-ups will be documented within 7 days after discharge when the client is referred for additional treatment and within 30 days when not referred for additional treatment.
Client record #6 was discharged on February 1, 2010 as of July 2, 2010 there was no documentation of an attempt to follow-up on the client.
Client record #8 was discharged on January 12, 2010 as of July 2, 2010 there was no documentation of an attempt to follow-up on the client.
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Plan of Correction
709.53(a)(11) Follow-up information: On July 13, 2010 and July 14, 2010 the Clinical Director met with the Clinical Staff in a group format to review and retrain staff on proper follow-up procedures / documentation, emphasizing the appropriate completion of the facility's 7-day follow up procedures. The Clinical Director will also meet with individual counselors for monthly supervision on or before July 31, 2010 to review the proper procedures for conducting follow-up with clients. The Clinical Director, Corporate Clinical Director and Corporate Compliance Officer will monitor compliance through monthly and random chart audits beginning 7/31/10. |