Observations
The facility failed to document follow-up information according to the facility's written policy and procedure manual reviewed on January 22, 2020.
The facility's policy manual indicated follow-up information would be documented within one week of the client's discharge from treatment.
Client # 1 was admitted February 4, 2019 and discharged May 23, 2019. Follow-up information was not documented until October 31, 2019.
Client # 2 was admitted April 2, 2019 and discharged June 24, 2019. Follow-up information was not documented until July 19, 2019.
Client # 3 was admitted April 4, 2019 and discharged December 3, 2019. Follow-up information was not documented until December 30, 2019.
Client # 4 was admitted March 20, 2019 and discharged May 22, 2019. Follow-up information was not documented until November 12, 2019.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
The Facility Director is responsible for the monitoring of follow up contacts for individuals who discontinue services. On January 23, 2020, the Facility Director developed and implemented a tracking system via a spreadsheet to ensure that the follow up contact occurs in accordance to the stated policy. The spreadsheet will be utilized to ensure that all follow up contacts occur in the manner and time frame required. |