Observations
Based on a review of the client records, the facility failed to document a personal history that included detail in the areas of the client's drug and alcohol history to include lengths and patterns of use, family history, legal history, medical history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history and sexual history in three of three records.
The findings Include:
Six records were reviewed September 22, 2011. Three records were reviewed for compliance with the regulations. Three records did not document personal histories that included all components of a personal history that are comprised the client's drug and alcohol history to include lengths and patterns of use, family history, legal history, medical history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history, and sexual history. Specifically, patient records # 1,2, and 3.
Record #1 - Client was admitted on 9-9-2011. The facility failed to document a personal history to include detail in the areas of the client's lengths and patterns of substance abuse.
Record #2 - Client was admitted on 9-15-2011. The facility failed to document a personal history to include detail in the areas of the client's lengths and patterns of substance abuse.
Record #3 - Client was admitted on 8-11-2011. The facility failed to document a personal history to include detail in the areas of the client's lengths and patterns of substance abuse and sexual history.
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Plan of Correction
Program Director and Clinic Supervisor will provide training to all staff on complete documentation of the patient's personal history that includes detail in the areas of the client's drug and alcohol history to include lengths and patterns of use, family history, legal history, medical history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history and sexual history. This process will be monitored by the Clinical Supervisor with staff and a sample of records will be reviewed to ensure that staff includes all components of the personal history. Staff currently has been advised verbally and a comprehensive training will be conducted within 30 days. |