Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in one of two applicable client records reviewed. Client #5 was admitted December 7, 2020 and was discharged March 9, 2021. There was no follow-up information documented in the record at the time of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Regional Quality Managers and Clinical Supervisors will be responsible for auditing a random sample of charts on a monthly basis. During these audits, charts will be checked to ensure 7 day follow up calls have occurred in a timely manner for discharged clients. Clinical Supervisors will discuss the findings of the chart audits in their individual supervision sessions with clinicians. |