Observations
Based on a review of client records, the facility failed to document follow up according to policy in two of four client records.
The findings include:
Eight inpatient client records were reviewed on July 29, 2010. Follow up documentation was required per agency policy of one month after discharge in four client records. The facility failed to provide follow up documentation in client records # 1 and 4.
Client # 1 was admitted on May 31, 2010 and discharged June 12, 2010. Follow up was due to be completed by July 12, 2010. There was no documentation of a follow up in client record #1.
Client # 4 was admitted on May 1, 2010 and discharged on May 4, 2010. Follow up was due to be completed by June 4, 2010. There was no documentation of a follow up in client record #4.
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Plan of Correction
Gateway recently updated it's follow-up policy . Follow-ups are to be conducted at around 30 days per policy. The Director of Research and Evaluation will monitor the follow-up process more closely to assure that it is being completed as stated in our policy. The Senior Director - Main Campus will also meet with the Director of Research and Evaluation to foolproof the follow-up process for main campus patients no later than September 30, 2010 |