Observations
Based on the review of patient records and an interview with the clinical supervisor, the facility failed to document an aftercare plan that included goals with time frames in two of two patient records.
The findings:
Twenty patient records were reviewed on August 11-12, 2010. Two patient records were required to have an aftercare plan completed. The facility did not document an aftercare plan that included goals with time frames in patient records # 13 and 14.
Patient # 13 was admitted on January 4, 2005 and successfully discharged on July 27, 2010. The aftercare plan, completed on July 27, 2010, did not include goals with time frames.
Patient # 1 was admitted on January 4, 2005 and successfully discharged on July 27, 2010. The aftercare plan, completed on July 27, 2010, did not include goals with time frames.
An interview with the clinical supervisor on August 12, 2010 confirmed the aftercare plans did not include goals with time frames.
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Plan of Correction
The aftercare plan used by SMS will be changed to reflect time frames for the goals outlined. Time frames will be in short-term (30-days) and long-term (90 days). This form has been changed and will be put into use upon the 8/24 staff meeting, where all staff can review how to properly complete this form.
The Facility Director is responsible for making the corrections to the aftercare plan and will be responsible for the implenetation with staff. |