Observations
Based on a review of client records, the facility failed to document a follow-up in four of five inpatient client records.
The findings include:
Six discharged inpatient client records were reviewed on June 19, 2013. Five of the clients reviewed required documentation of a follow-up. The facility did not document a follow up in client records # 6, 8, 9 and 10.
Client # 6 was admitted on September 25, 2012 and discharged on January 3, 2013. There was no follow up documented in client record #6.
Client # 8 was admitted on July 24, 2012 and discharged on March 15, 2013. There was no follow up documented in client record #8.
Client # 9 was admitted on October 15, 2012 and discharged on April 19, 2013. There was no follow up documented in client record #9.
Client # 10 was admitted on June 23, 2012 and discharged on July 9, 2012. There was no follow up documented in client record #10.
Each of the aforementioned client records contained a note labeled "follow up" which was written on the day of discharge and did not indicate that contact was attempted or made with the discharged client.
The findings were reviewed with the project director and clinical supervisor on June 19, 2013 and were not disputed.
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Plan of Correction
All Residential Counseling Staff will be informed Wednesday July 3, 2013 in the staff meeting that Follow up documentation isn't valid on the day of discharge. Follow up documentation is to occur within seven (7) days after the date of discharge by the Residential Counselor completing the discharge. This will be evidenced on the follow up sheet in the client file. The Executive Director is responsible for informing the counselors and documentation of notification will be evidenced through the staff meeting minutes. |