Observations
Based on a review of client records, the facility failed to complete case consultations according to facility policy and procedures in three of seven records reviewed. Per facility policy and procedures, case consultations are to be completed weekly.
Client #4 was admitted November 26, 2024 and discharged December 30, 2024. There was no documentation of a case consult being completed for the weeks of: December 8 and December 15, 2024.
Client #5 was admitted December 23, 2024 and discharged February 1, 2025. There was no documentation of a case consult being completed for the weeks of: December 29, 2024, January 12, January 19, and January 26, 2025.
Client #6 was admitted January 28, 2025 and discharged February 27, 2025. There was no documentation of a case consult being completed for the weeks of: February 2, February 9, and February 16, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The case consultation note will be completed for all clients on a weekly basis. This process was reviewed with clinical staff during the team meeting on 5/20/2025. In addition, one individual counselor received specific direction related to this process. The clinical supervisor will review this process again with clinical staff as needed to ensure understanding of the process. The clinical supervisor is responsible for oversight of the full process and compliance with the standard.
To help facilitate review and compliance of this process, a report was created within the EHR to monitor completion of case consultation notes. The clinical supervisor and risk management team will monitor completion of case consultation notes and monitor ongoing compliance with this standard. The facility is in full compliance with this standard as of 5/23/25.
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