Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include follow-up information, in two of three applicable client records reviewed.Client #6 was admitted on September 13, 2022 and was discharged on October 29, 2022. The client record did not contain documentation of follow-up information.Client #7 was admitted on September 21, 2022 and was discharged on November 26, 2022. The client record did not contain documentation of follow-up information.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All client records, whether the client has completed or were non compliant, will be a complete client record that includes a follow up and follow up information. All counselors will meet with the clinical director to ensure that all client records have a complete file including all follow up information of all clients regardless if they completed or were discharged as noncompliant. This will go into effect on April 26, 2023 and remain in effect for all counselors and all of the client charts. |