Observations
Based on a review of client records, the facility failed to document quarterly case consultations in three of ten client records.
The findings include:
Ten client records were reviewed on October 23-24, 2013. The facility failed to document quarterly case consultations in client records # 2, 3 and 4.
Client # 2 was admitted on February 13, 2013. Case consultations were due to be completed by May 13 and August 13, 2013. There were no case consultations documented in client record # 2 as of the date of inspection.
Client #3 was admitted on April 2, 2013. Case consultations were due to be completed by July 2 and October 2, 2013. There were no case consultations documented in client record # 3 as of the date of inspection.
Client #4 was admitted on May 21, 2013. A case consultation was due to be completed by August 21, 2013. There were no case consultations documented in client record # 4 as of the date of inspection.
The aforementioned information was discussed and confirmed with the clinical supervisor and facility director on October 24, 2013.
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Plan of Correction
A Clinical meeting will be held on 11/5/13 to explain the importance of completing the quarterly case consults. Effective 12/31/13, all frug free patient will have a quarterly consult documented in the patients electronic file. The Clinical Supervisor will monitor the electronic files for compliance. The Program Director will do sporadic checks to monitor compliance. |