Observations
Based on the review of outpatient client records, the project failed to document a complete client record on an individual that included case consultation notes in two of six applicable client records reviewed.Client #5 was admitted on January 23, 2024 and was discharged on April 30, 2024. A case consultation note was not documented in the client ' s record prior to discharge.Client #7 was admitted on April 29, 2024 and was discharged on September 27, 2024. A case consultation note was not documented in the client ' s record prior to discharge.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Brighter Visions Counseling acknowledges and pledges compliance with 709.93(a)(8) pertaining to client records. Upon completion of treatment the Counselor will conduct a consultation with the Director or another Counselor regarding the preparation of the case for closing. This consultation will review standards of treatment, i.e. goals, objectives, and measures of success. This consultation will be documented in the client record. This POC is in place on December 9, 2024. The application of this Plan of Correction is the responsibility of the Director |