Observations
Nine client records were reviewed for the renewal inspection on February 9, 2017. The facility failed to ensure that a complete record was documented in client records # 4, 5, and 9.
Client # 4 was admitted into treatment on 5/16/16 and was discharged on 8/16/16. An attempt to follow-up with the client was not documented in the client's record.
Client # 5 was admitted into treatment on 4/26/16 and was discharged on 10/14/16. An aftercare plan was not documented in the client's record. In addition, an attempt to follow-up with the client was not documented in the client's record.
Client # 9 was admitted into treatment on 6/3/16 and was discharged on 8/25/16. An attempt to follow-up with the client was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During the 2/23/17 staff meeting, all clinical and administrative staff were re-educated on proper discharge procedures including completing an aftercare plan for each client who successfully completes treatment and sending follow-up questionnaires to all discharged clients. Office administration will ensure ongoing compliance by auditing each discharge chart for applicable discharge paperwork. The Quality Improvement Department will also conduct random audits to ensure compliance. |