Observations
Based on a review of client records, the facility failed to document follow-up information in two of two applicable records.
The facility's policy and procedures state telephone follow-ups are completed three, seven, and thirty days after discharge.
There was no follow-up information documented in client records #10 and #12.
Client #10 was admitted to the detox level of care on September 9, 2024, and discharged on September 13, 2024.
Client #12 was admitted to the detox level of care on March 3, 2025, and discharged on March 6, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward
client follow ups will be completed on a three, seven, and thirty days after discharge as stated in the facility policy .Reminders will be set in the EHR. Staff will also be trained on the follow up process effective immediately
Facility Director will conduct chart
audits on a routine basis. |