Observations
Based on a review of client records, the facility failed to have a complete record in four of ten records reviewed.
The findings include:
Ten client records were reviewed on September 12, 2014. Four client records failed to have a complete record, #6, 7, 8 and 9.
Client #6 was discharged, successfully, on January 2, 2014. The facility documented the aftercare plan on January 2, 2014, but the aftercare plan failed to include the client's goals with time frames, contact person and reentry process.
Client #7 was discharged, successfully, on March 12, 2014. The facility failed to have documented client #7's aftercare plan. Additionally, the facility failed to document a follow-up attempt.
Client #8 was discharged, successfully, on March 3, 2014. The facility failed to have documented client #8's aftercare plan. Additionally, the facility failed to document a follow-up attempt.
Client #9 was discharged, successfully, on June 24, 2014. The facility documented the aftercare plan on June 24, 2014, but the aftercare plan failed to include the contact person and reentry process.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will retrain all clinical staff in the proper completion of all treatment forms and documentation including timelines at the clinical staff meeting on 10/10/2014. Clinical documentation will be reviewed by the Program Director monthly for existing staff and weekly for all probationary staff.Clinical Documentation review will be documented in the Open and Closed Chart Monitors. Monitors will be reviewed by the Vice President of Clinical Services |