Observations
Based on a review of client records, a review of the facility's policy and procedures manual, and an interview with the facility director, the facility failed to document a complete client record per policy in one of three client records.
The findings include:
Nine client records were reviewed on January 11, 2011.
Three records required documentation of a discharge summary.
The facility failed to document a discharge summary per policy in client record # 3.
The facility's policy and procedure for client discharge specified that the clinician completed a discharge summary within one week following termination of treatment.
Client # 3 was admitted to the program on 6/8/10.
Client # 3 was discharged on 10/5/10, per the documentation of progress note, aftercare plan, and discharge summary.
The discharge summary should have been complete by 10/12/10, however the facility did not document a discharge summary until 11/10/10.
The facility director confirmed that the discharge summary was documented late.
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Plan of Correction
On January 13, 2011 the assigned clinical supervisor met with the clinician assigned to client #3 and reviewed licensing standard 709.93 (a)(10) which states there shall be a complete client record on an individual which includes information relative to the client's involvement with the project; and that this shall include, but not be limited to, a Discharge Summary. The assigned supervisor also reviewed Agency Policy with the clinician which stipulates that a Discharge Summary must be completed within one week following termination of treatment. The assigned supervisor will continue to monitor the record documentation of the clinician assigned to client #3, with special attention to timely completion of the required Discharge Summary.
On January 24, 2011 the Director of Clinical Services and the Clinical Supervisors met with the Clinical Staff members. During this staff meeting the Director of Clinical Services reviewed both licensing standard 709.93 (a)(10) as well as Agency policy which specifies that a Discharge Summary must be completed within one week following the termination of treatment. The Director of Clinical Services informed staff meeting participants that as supervisors regularly monitor record documentation, they will be giving particular attention to the timely completion of the required Discharge Summary.
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