Observations
Based on the review of client records, the facility failed to ensure that a complete record was documented in nine of nine client records reviewed.
The findings include:
Nine client records were reviewed for documentation of a complete client record during methadone monitoring on 8/20/15 and 8/21/15. In all nine client records reviewed, the facility failed to document lab results of urine tests since the implementation of an electronic client record keeping system in January 2015.
Client # 1 was admitted into treatment on 12/20/13. The client's record did not contain lab results of urine tests completed for the client after December 2014.
Client # 2 was admitted into treatment on 5/26/15. The client's record did not contain lab results of urine tests completed for the client.
Client # 3 was admitted into treatment on 10/1/13 and was discharged on 8/19/15. The client's record did not contain lab results of urine tests completed for the client after December 2014.
Client # 4 was admitted into treatment on 2/26/15 and was discharged on 7/6/15. The client's record did not contain lab results of urine tests completed for the client.
Client # 5 was admitted into treatment on 7/3/14. The client's record did not contain lab results of urine tests completed for the client after December 2014.
Client # 6 was admitted into treatment on 5/11/15. The client's record did not contain lab results of urine tests completed for the client.
Client # 7 was admitted into treatment on 6/4/15. The client's record did not contain lab results of urine tests completed for the client.
Client # 8 was admitted into treatment on 8/18/14. The client's record did not contain lab results of urine tests completed for the client after December 2014.
Client # 9 was admitted into treatment on 2/24/77. The client's record did not contain lab results of urine tests completed for the client after December 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective October 1,2015, Urine Drug Screens for all JFK clients will be scanned into the electronic health record of each client. The administrative assistant will be trained by the supervisor to accurately scan files into the appropriate client record. The clinical supervisor will be responsible for monitoring the scanning process and ensuring compliance with this standard. |