Observations
Based on the review of client records and a review of the policy and procedures manual, the facility failed to document follow-up information within 7 days from the date of discharge in 4 of 5 client records.
The findings include:
Ten client records were reviewed on May 12 - 13, 2010.
Five client records required documentation of follow-up information.
The facility failed to document follow-up within 7 days from the date of discharge, as per facility policy, in client records # 6, 7, 8, and 9.
The facility's policy on follow- up states:
Follow Up: Within seven (7) days of the date of a referral appointment made for a client leaving treatment, the referral shall be contacted by the Counselor to determine if the client kept the initial appointment and if the referral was appropriate.
In the case of a client ending treatment without a referral appointment (ASA, Therapeutic Discharge, Completion who refuses further treatment), the client shall be contacted directly by the counselor or supervisor ' s designee to determine the client ' s well-being and to maintain the opportunity for re-admission should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge.
Information shall be kept in the follow up log binder.
Client # 6 was admitted to the program on 11/27/09 and discharged on 3/19/10. The follow-up log verified that contact was made; however, it failed to document the date of contact.
Client # 7 was admitted to the program on 8/25/09 and discharged on 12/28/09, follow-up was not documented at the time of review on 5/13/10.
Client # 8 was admitted to the program on 9/23/09 and discharged on 1/11/10, follow-up was documented on 3/4/10.
Client # 9 was admitted to the program on 7/14/09 and discharged on 11/30/09, follow-up was not documented.
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Plan of Correction
The Clinical Supervisor will ensure that the aftercare specialist adheres to the established protocol.
The Protocol:
Within the first seven days of after discharge from the program, the Aftercare Specialist will initiate contact with all clients or Aftercare Facility. The Aftercare Specialist can make contact by phone or by way of visit. After the initial follow-up is completed, the contacts are made on a 30-day interval basis thereafter.
Follow up- information
Client #7 follow-up was done on 1-3-10 and #9 follow-up was done on 12-6-09. Both clients were done within the seven day timeframe and the documentation has been added to the client's chart and the follow-up log binder to show that the follow-up protocol has been complete in the appropriate time frame. The follow-up was done by the Food Service Supervisor and the UR Specialist.
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