Observations
The facility failed to document a complete client record, including follow up information in 5 of 5 client records.
Ten client records were reviewed on August 25, 2016. Five of the clients reviewed were discharged and required documentation of follow up contact. Client records # 6, 7, 8, 9 and 10 did not include documentation of follow up contact.
Client #6 was admitted on 11/16/15 and discharged on 4/15/16. There was no documentation of follow up contact in client record #6.
Client #7 was admitted on 1/15/16 and discharged on 6/22/16. There was no documentation of follow up contact in client record #7.
Client #8 was admitted on 5/11/16 and discharged on 8/18/16. There was no documentation of follow up contact in client record #8.
Client #9 was admitted on 4/13/16 and discharged on 7/15/16. There was no documentation of follow up contact in client record #9.
Client #10 was admitted on 11/4/15 and discharged on 3/5/16. There was no documentation of follow up contact in client record #10.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc.shall document follow-up information in the client record. When a client has been discharged and referred to an outside resource, Renewal Treatment, Inc. with written consent of the client will follow up on the disposition of that client no later than one week after the designated referral date. All clients who have completed treatment will be contacted for follow up within one year after discharge. The client's AOD Counselor shall be responsible for following-up with their discharged clients and documenting it in the client's record. The Clinical Supervisor has provided the AOD Counselors with instruction on this requirement. The Clinical Supervisor shall ensure compliance during weekly supervision and regular file reviews. This plan of correction is in place. |