Observations
Based on a review of client records, the facility failed to provide a complete client record on each individual in two of three client records.
The findings include:
Three client records were reviewed on October 29, 2013. Two of the three client records did not provide a complete client record for an individual in records #5 and 6.
Client record #5 was admitted to outpatient treatment on August 1, 2013. The record of service was missing entries for the duration of services for a group session on August 29, 2013, an individual session on October 15, 2013, and a group session on October 16, 2013. The record also included a case consultation documented on August 16, 2013 that was missing a disposition.
Client record #6 was admitted to outpatient treatment on March 5, 2013 and discharged on June 21, 2013. Documentation of a follow up was to be completed within a week and was not documented as of October 29, 2013.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
1) Program Director will review policies and standards with all staff during a staff meeting by 12/09/2013.
2)Duration of service will be documented on each client record. All case consults will include a disposition. This will be monitored through the monthly quality improvement/utilization review meeting.
3) Program Director, Administrative Coordinator, and the Administrative Assistant will monitor follow up weekly to assure they are being completed within a week of discharge. Program Director will review follow-up process with Division Director monthly during program meeting. |