Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow up information in one out of three records reviewed.
Client #6 was admitted on November 3, 2022 and discharged on February 6, 2023. There was no documentation of follow up information in the record.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The program's clinical staff will assure documentation of follow-up post client discharge in all applicable records in conformance with licensing regulations.
A follow up form has been integrated into facility electronic health record program, to be utilized by clinical staff. All staff have been trained on utilization of this form.
Ongoing conformance will be monitored via monthly record audits performed by the Clinical Supervisor, Program Director and the Continuous Quality Improvement Department.
|