Observations
Based on a review of patient records and the Counseling Treatment policy, the facility failed to follow their written procedures for ongoing management of treatment/rehabilitation services in one of eight patient records reviewed.
Per the Counseling Treatment policy, within 7 days post-discharge, the counselor shall complete the discharge summary.
Client # 7 was admitted on November 2, 2023, and discharged November 21, 2023. The discharge summary should have been completed no later than November 28, 2023. Documentation shows the discharge summary was dated January 8, 2024.
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Plan of Correction
Until such time that at least 90% of all counseling discharge summaries are completed timely, the Director of Clinical Services, or designee, shall complete a weekly audit of Counseling Discharge Summaries to identify any deficiencies. Following a minimum of 4 weeks with at least 90% compliance, the Director of Clinical Services, or designee, shall complete an audit of Counseling Discharge Summaries at a minimum of monthly to identify any deficiencies for a minimum of 3 months.
All staff who do not meet performance expectations of 90% compliance with timely completion of counseling discharge summaries for three or more weeks will receive documented supervision on the policy requirements for counseling discharge summary.
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