Observations
Based on a review of client records, the facility failed to produce a complete client record on an individual which included information relative to the client's involvement with the project.
The findings include:
An onsite complaint investigation was completed on July 9, 2013. Client and staff interviews were conducted and a review of client records was completed. One of the client records requested , #13, was unable to be located.
Client #13 was admitted on October 25, 2012 and discharged on April 23, 2013.
The aforementioned information was confirmed by the lead counselor.
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Plan of Correction
POWER will maintain and have access to a complete client record on every individual's involvment in the facility. To acheive this objective the following plan will be fully implemented by 9/9/2013.
The Associate & Clinical irector will provide oversight to the following plan of correction:
The Program Manager and Lead Therapists will ensure that a Client Record is developed, maintained and completed on every client involved with the project via ongoing quality assurance activities and staff supervision.
The Associate & Clinical Director, Program Manager , and Lead Therapist will review the Agency policies related to staff access and client records.
The Program Manager will routinely monitor that staff are compliant with the policies and procedures and intervene as needed, including consulting with the Associate & Clinical Director for any issues with compliacne. Specifically, the Program Manager will ensure the availablity and timely access to the client record by doing the following:
Review and enforce with staff the process to ensure client records are locked at all times whe not in use.
Ensure a process is in place that serves to monitor and track staff accountability and location of the the client record.
Train facility staff in the procedures to managing and storing client records.
Ensure access to client records is limited to select staff.
Provide adequate supervision of support staff that is responsible for filing client records.
Routinely monitors on site file room where client records are stored after discharge to make sure client recoreds are being filed and maintained in an orderly and timely manner. |