Observations
Based on a review of client records, the facility failed to document a complete client record on an individual in four of eleven client records reviewed.
The findings include:
Eleven client records requiring a complete client record on an individual were reviewed on February 11, 2016. Specifically, the facility did not provide follow-up information in client records, #6, 7, 9, and 10.
Client #6 was admitted into treatment on May 27, 2015 and was discharged on August 27, 2015. The facility failed to include documentation of any follow-up information as of the date of the inspection.
Client #7 was admitted into treatment on February 18, 2015 and was discharged on December 16, 2015. The facility failed to include documentation of any follow-up information as of the date of the inspection.
Client #9 was admitted into treatment on November 24, 2015 and was discharged on January 25, 2016. The facility failed to include documentation of any follow-up information as of the date of the inspection.
Client #10 was admitted into treatment on June 4, 2015 and was discharged on August 24, 2015. The facility failed to include documentation of any follow-up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning on 2/15/2016, ALL discharge summaries will include a discharge letter explaining that the patient is no longer under the care of the Caring Together Program, and for what reason. In addition, the letter will explain how to contact the program to re-enroll if applicable. The letter will be sent when the discharge summary is completed (as it is an addendum to the current discharge summary), and this will be completed within 30 days of the patient's official discharge from the program.
For client records #6, 7, 9, and 10, a follow up letter will be immediately (2/29/2016) sent to each participant with information on how to reapply and why their case was discharged. |