Observations
Based on a review of client records and an interview with the clinical supervisor and project director, the facility failed to document a complete client record on an individual in four of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a complete client record, which included aftercare plan goals with timeframes and client related correspondence were reviewed on February 7, 2014. The facility failed to include timeframes with the documented aftercare plan goals in client records #6, 8, and 10. Additionally, the facility failed to include client related correspondence in client record #2.
Client #6 was admitted to treatment on 12/05/13 and was discharged on 02/06/14. The aftercare plan contained in client record #6 was signed by the client; however, there were no timeframes provided with the client's documented aftercare plan goals.
Client #8 was admitted to treatment on 04/11/13 and was discharged on 06/03/13. The aftercare plan contained in client record #8 was signed by the client; however, there were no timeframes provided with the client's documented aftercare plan goals.
Client #10 was admitted to treatment on 09/19/13 and was discharged on 12/14/13. The aftercare plan contained in client record #10 was signed by the client; however, there were no timeframes provided with the client's documented aftercare plan goals.
Additionally, Client #2 was admitted to treatment on 12/30/13 and was still active at the time of the on-site inspection. There was a progress note, dated 11/25/13, that stated that a letter was sent; however, there was no further notation of what the letter was regarding and to whom the letter was sent to. In addition, there was no documentation of the letter in the client record.
The Project Director and the Clinical Supervisor did not dispute the findings.
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Plan of Correction
The clinical supervisor, M. Jason Radosky, will be responsible for reviewing all of the therapist's aftercare plans for clients. Each aftercare plan will be reviewed to ensure timeframes are present and, if not, it will be brought to the therapist's attention, which will result in the client being contacted to develop time frames for goals.
An email was sent to all licensed employees that documentation of letters being sent to clients must be copied and placed in the corresponding client's file. The supervisor of the program will review documentation/progress notes and if reference is made to a letter being sent, they will ensure a copy of letter is within the client file. This will start immediately, 3/18/2014. |