Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in two of four applicable client records reviewed.
The facility's policy and procedure manual stated that follow-up calls will be completed within seven days of discharge.
Client # 4 was admitted on December 11, 2025 and was discharged on January 9, 2026. The follow-up call was due to be completed by January 16, 2026; however; the follow-up contact/information was documented on February 5, 2026.
Client # 5 was admitted on August 14, 2025 and was discharged on October 10, 2025. The follow-up call was due to be completed by October 17, 2025; however; the follow-up contact/information was documented on October 24, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Facility Director reviewed findings from the DDAP audit with SUD clinicians on February 12, 2026.
2. Clinical Supervisor held a re-training during supervision on DDAP compliance standards on February 17, 2026. This training covered the discharge process and the need for follow up calls within 7 days of discharge. Clinicians have been provided with resources in the counselor manual that detail all quality and compliance expectations.
3. Facility Director and Clinical Supervisor asked clinicians to begin scheduling discharge follow up calls within 7 days of discharge in their EMR schedule. The due date for this directive was February 24, 2026.
4. Clinical supervisor will continue monthly chart audits for each clinician to be reviewed in supervisions. Clinicians will have 2 weeks to make any needed corrections.
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