Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which is to include aftercare plans and follow-up information in four of ten client records reviewed.
The findings include:
Ten client records requiring a complete client record on an individual were reviewed on September 29, 2015. The facility did not provide a complete client record for client #s 5, 6, 7, and 9.
Client #5 was admitted into treatment on November 19, 2014 and was discharged on March 9, 2015. The facility failed to include documentation of any follow-up information as of the date of the inspection.
Client #6 was admitted into treatment on January 9, 2014 and was discharged on February 28, 2015. The facility failed to include documentation of any follow-up information as of the date of the inspection.
Client #7 was admitted into treatment on August 25, 2014 and was discharged on March 27, 2015. The facility failed to include documentation of any follow-up information as of the date of the inspection.
Client #9 was admitted into treatment on July 24, 2014 and was discharged on January 16, 2015. The facility failed to include documentation of any follow-up information as of the date of the inspection. Additionally, the client was discharged as completing treatment, yet the facility failed to include documentation of an aftercare plan in the client chart as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical supervisor will review in staff meeting the standard and policy requiring that outreach attempt be completed within 7 days post discharge as well as the aftercare policy. The Discharge Summary form has been amended to reflect multiple discharge status options as well as an area for documenting the 7 day follow up. Compliance with this standard will be ensured by the clinical supervisor via monthly chart audits and reinforced quarterly at the staff meeting. This goal will be achieved by 11-15-2015. |