Observations
Based on the review of client records, the facility failed to document follow up in one of two client records.
The findings include:
Sixteen client records were reviewed on March 24-26, 2009. Eight of the client records reviewed were for the outpatient program. Follow up was required in two outpatient client records. The facility did not document follow up contact attempts in client record # 16.
|
Plan of Correction
The treatment specialists are responsible for providing the follow up forms to the Program Supervisor when a client is discharged from treatment. The Program Supervisr compiles a list of all discharged clients in the month to ensure that the treatment specialists have turned in forms for all clients discharged. If a form is missing for a client, the Program Superviosr communicates this to the treatment specialist, directing them to complete a follow up form. With the file in question, the treatment specialist failed to complete the form when the client was discharged. Although the Program Supervisor noticed that the follow up form was missing and directed the treatment specialist to submit the form, the treatment specialist did not submit the form and the Program Supervisor did not follow up to ensure that the form was submitted.
The plan of correction for this issue is that the Program Supervisor reviewed the follow up procedure with all clinical staff at the team meeting on 4/2/2009. Also, from this point on, the Program Supervisor will cross check the list of required follow up forms at the end of each month to ensure that all follow up forms are received by the treatment specialists. The treatment specialists will be given a deadline to submit follow up forms to the Program Supervisor each month. Once all follow up forms are accounted for by the Program Supervisor, the Supervisor will then turn the forms over to Clinical Assistant staff to make follow up contacts with the clients. |