Observations
Based on an interview with the Director at the time of the onsite inspection of 2/24/2010, the facility failed to ensure that client records were secured in locked storage containers.
The findings included:
At the time of the onsite inspection, the Facility Director stated that there was one active client record for review at this location. Upon arrival at the facility, the client record could not be located. The Director was informed by administrative staff at the main Cen Clear office in Philipsburg that the likely location of the record was with the counselor who had just resigned. The employee may have transported the record from the facility in violation of facility policy which specifies that records are to be kept in locked storage containers at the facility. The location of the client record was unknown at the time of the inspection.
|
Plan of Correction
During the exit interview and review with the staff person who resigned from the DA position in Coalport it was discovered that this counselor was unable to contact the client and open for services. There was no active chart at this time. It was misunderstood by the Facility Director that this client was active and was seen at least once upon assigning case to the staff. Since her resignation, this case hss been reassigned to new therapist to open as an active client. In addition, CCS will be implementing electronic charts in the very near future where there will be no need for hard copy charts that could be lost, transferred etc. We have also implemented a policy as to the therapist must report opening date of a client to the Project Director within 24 hrs. |