Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in two of three applicable records reviewed.
Client #2 was admitted January 29, 2020 and was discharged September 12, 2021. There was no documentation of follow-up information in the record as of the date of the inspection.
Client #4 was admitted February 12, 2021 and was discharged April 7, 2021. There was no documentation of follow-up information in the record as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As of June 2021, we have updated our electronic discharge management plan by merging the plan into a bundle. Included in the bundle is a call log to document a 7 day follow up call. Clinicians cannot complete the entirety of the bundle with a final signature without documenting a 7 day follow up call in the bundle.
We are also increasing the number of charts being audited on a monthly basis in order to ensure discharge management plans and follow up calls are being completed in a timely manner.
Regional Quality Managers and Clinical Supervisors will be responsible for ensuring the follow up calls are being completed. |