Observations
Based on a review of client records and an interview with the project director and administrative officer, the facility failed to document a case consultation, as per agency policy, of every 90 days in four of twelve client records.
The findings include:
Eighteen outpatient client records were reviewed on May 25-27, 2010. Twelve of the client records reviewed required case consultations. Per agency policy, case consultations shall be completed every 90 days. The facility did not document case consultations within the 90 day time frame in client records # 1, 3, 17 and 18.
Client # 1 was admitted on November 17, 2009. The case consultations were due by February 17, 2010 and May 17, 2010. There were no case consultations documented in client record # 1.
Client # 3 was admitted on July 7, 2009. The case consultations were due by October 7, 2009, January 7, 2010 and April 7, 2010. The only case consultations documented were dated September 1, 2009 and November 3, 2009.
Client # 17 was admitted on December 15, 2009. A case consultation was due by March 15, 2010. There were no case consultations documented in client record # 17.
Client # 18 was admitted on December 29, 2009. A case consultation was due by March 29, 2010. There were no case consultations documented in client record # 18.
Interviews took place with the project director and administrative officer on May 25 and 27, 2010 at which time it was confirmed that the above mentioned case consultations were not documented.
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Plan of Correction
Results of survey will be reviewed with all Clinical Staff at a Clinical Staff Team Meeting. The agency policy regarding 90 day time frame for case consultations will be reviewed and provided to all Clinical Staff. Increased one on one clinical supervision with specific counselor to review charts and ensure 90 day case consultation is completed, reviewed, and documented per agency and licensing guidelines. Random monthly Chart Audits by Clinical Director and Executive Director will be conducted as part of the supervision plan. |