Observations
Based on a review of client records, the facility failed to complete case consultations in three of six applicable records reviewed. Per agency policy and procedures, case consultations are to be completed within 90 days of admission.
The following client records did not include case consultations.
Client #2 was admitted on January 8, 2025 and discharged on April 22, 2025.
Client #3 was admitted on January 9, 2025 and discharged on April 30, 2025.
Client #4 was admitted on December 13, 2024 and discharged on April 30, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Case Consultations will be completed and documented within required timeframes.
The Clinical Director will review policies and expectations with all staff regarding case consultations time frames by 9/19/25.
Administrative staff will run a report to identify needed case consultations to be reviewed bi-weekly in staff meetings.
If a Clinician is out of compliance this will be discussed in a documented clinical supervision session, and a Performance Improvement Plan will be initiated. Progress will be monitored via monthly chart reviews. The Clinical Director will review progress during monthly supervision sessions. Any required corrections will be completed within 72 hours. |