Observations
Based on a review of client records, the facility failed to document follow-up information in two of three client records.
The findings include:
Nine client records were reviewed on June 18, 2013. Four client records were closed and three closed records required a follow-up attempt. Per the project's policy and facility director, a follow-up attempt will be conducted for all clients within 7 days of discharge. The facility failed to document a follow-up attempt in client records # 6 and 7.
Client # 6 was admitted into treatment on March 15, 2013 and discharged on May 29, 2013. A follow-up attempt was due to be completed no later than June 5, 2013. There was no documentation of follow-up information in client record # 6.
Client # 7 was admitted into treatment on December 31, 2012 and discharged on June 6, 2013. A follow-up attempt was due to be completed no later than June 13, 2013. There was no documentation of follow-up information in client record # 7.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Program Manager will ensure that all staff are trained on the requirement that all clients regardless of type of discharge shall have a follow up completed and documented within 7 days of discharge by 7/30/13. The Program Manager will also complete a file review on all discharged files to ensure that the followup occurs and is documented on an ongoing basis. |