Observations
Based on an interview with the facility director, the facility failed to maintain a data collection and record keeping system that allows for the efficient retrieval of data.
The findings include:
An interview with the facility director took place on 1/6/14, at which time it was requested that a list of both current and discharged clients that was to include the name of the clients, dates of admission and the dates of discharge. The only list of clients that the facility was able to produce was a list of the names of the clients were presently in treatment as of 1/6/14, which did not include dates of admission. Additionally, the facility was not able to produce a list of discharged clients that included the dates of admission and discharge for the purpose of randomly selecting client records for the annual licensing inspection. During the exit conference, the licensing specialist was informed that the information was maintained in a database on the computer, but staff have not been adequately trained on the use of the database to produce the requested information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Resident tracking software that responds to the need of maintaining data collection and record keeping is already in place and has been updated to include the name of the clients, dates of admission and dates of discharge; and shall allow for the efficient retrieval of data.
This system shall be maintained and utilized for facility data collection and record keeping.
The Director shall ensure that all clinical staff is adequately trained on the use of the software and able to produce requested information. Training is scheduled for February 5, 2015, and will be continued to be offered as needed/requested. |
Observations
Based on the review of client records, the facility failed to ensure that a complete record was documented in five of ten client records reviewed.
The findings include:
Ten client records were reviewed for documentation of a complete client record during the renewal inspection on 1/5/15 through 1/6/15. The facility failed to document a complete record in client records # 5, 6, 7, 8 and 10.
Client # 5 was admitted on 8/25/14 and discharged on 12/27/14. The record of service for the client indicated that the client attended a group counseling session on 11/6/14. A progress note was not documented in the client's record for this group counseling session.
Client # 6 was admitted on 7/8/14 and was still an active client at the time of inspection. The record of service for the client indicated that the client attended individual counseling sessions on 9/16/14, 10/29/14, 11/25/14, 12/23/14; and group counseling sessions on 9/25/14, 9/26/14, 9/30/14, 10/2/14, 10/3/14, 10/7/14, 10/9/14, 10/10/14, 10/14/14, 10/16/14, 10/21/14, 10/23/14, 10/24/14, 10/27/14, 10/28/14, 10/29/14, 11/6/14, 11/7/14, 11/10/14, 11/11/14, 11/18/14, 11/20/14, 11/21/14, 11/24/14, 12/2/14, 12/8/14, 12/16/14, 12/23/14 and 12/30/14. No progress notes were documented in the client's record for these individual and group counseling sessions.
Client # 7 was admitted on 9/19/14 and was still an active client at the time of inspection. The record of service for the client indicated that the client attended an individual counseling session on 12/30/14 and group counseling sessions on 11/3/14, 11/4/14, 11/6/14, 11/7/14, 11/10/14, 11/11/14, 11/13/14, 11/14/14, 11/18/14, 11/20/14, 11/24/14, 11/25/14, 12/1/14, 12/2/14, 12/5/14, 12/8/14, 12/9/14, 12/11/14, 12/15/14, 12/16/14, 12/19/14, 12/22/14, 12/23/14 and 12/30/14. No progress notes were documented in the client's record for these individual and group counseling sessions.
Client # 8 was admitted on 4/28/14 and discharged on 8/24/2014. A record of service for August 2014 was not documented in the client's record.
Client # 10 was admitted on 7/10/14 and discharged on 12/20/14. The record of service for the client indicated that the client attended group counseling sessions on 9/29/14, 12/4/14, 12/5/14, 12/8/14, 12/9/14, 12/11/14, 12/12/14, 12/15/14, 12/16/14, 12/18/14 and 12/19/14. No progress notes were documented in the client's record for these group counseling sessions.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for noncompliance of this standard during the 3/11/14 supervisory review of the 2/10/14 licensing inspection and the 8/22/14 follow up inspection.
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Plan of Correction
There shall be a complete chronological listing of the client record for every service for every individual which shall include all information relative to the client's involvement with the project. This shall include but not be limited to everything from the intake process to the after-care and follow-up plan.
This record shall be found at all times within the client file and be accurate to the day.
Progress notes shall be documented and filed in the client record after each significant contact.
The Clinical Supervisor and Counselor shall ensure by weekly inspection of client files that a daily and accurate record of service is being maintained.
Supervisory audits by a Clinical Administrator shall occur monthly to ensure compliance with this plan of correction. |