Observations
Based upon a review of eight client records on May 30, 2008 the facility failed to document the dosage, frequency and or medication in one of three client records where medications were applicable.
Record #3 simply listed "antibiotic for toothache" under the heading of medication and was missing the name of the medication, the dosage and the frequency of use.
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Plan of Correction
In the client record, specifically in reference to medication records, if a client is prescribed and taking medication the counselor will document the medication, the dosage and frequency of use of the medication. Clinical supervisor will review with all clinical staff this procedure at clinical meeting. All clinical staff will sign off that they have received and reviewed this procedure.In the client record, specifically in reference to medication records, if a client is prescribed and taking medication the counselor will document the medication, the dosage and frequency of use of the medication. Clinical supervisor will review with all clinical staff this procedure at clinical meeting. All clinical staff will sign off that they have received and reviewed this procedure. In order to ensure continued compliancy, clinical files will be reviewed on a monthly basis by the program supervisor and reported during the monthly QI meetings. This process will be ongoing. |