Observations
Based on a review of client records and an interview with the clinical supervisor and facility director, the facility failed to document an aftercare plan that included goals with time frames in three of three client records.
The findings include:
Twenty client records were reviewed on August 2 & 3, 2011. Three of the clients reviewed were discharged as successful completions. All three of those client records were required to have an aftercare plan including goals with timeframes, support services, contact person and reentry process. The facility did not document an aftercare plan which included goals with timeframes or support services in client records #18 and 19. The aftercare plan contained in client record #20 did not include goals with timeframes.
Client #18 was admitted to treatment on January 14, 2008 and discharged successfully on October 4, 2010. The aftercare plan contained in client record #18 was signed by the client; however, there were no goals with timeframes or support services documented. These sections were left blank.
Client #19 was admitted to treatment on June 18, 2009 and discharged successfully on May 22, 2011. The aftercare plan contained in client record #19 was signed by the client; however, there were no goals with timeframes or support services documented. These sections were left blank.
Client #20 was admitted to treatment on July 7, 2006 and discharged successfully on October 18, 2010. The aftercare plan contained in client record #20 was signed by the client; however, there were no goals with timeframes documented. This section was left blank.
An interview with the the clinical supervisor and facility director took place on August 3, 2011. The aforementioned information was confirmed.
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Plan of Correction
The Facility Director will make necessary changes in the Aftercare Plan Document itself, by 8/17/11. Changes will include ensuring that the aftercare plan contains quantitative goals with timeframes for completions, a list of supportive services, contact persons indicated for supportive serives and a description of the re-entry process for Summit medical Services. These changes will be presented in the 8/24 staff meeting.
Also, the Facility Director will instruct all staff in how the Aftercare Plan will be administered in the 8/24/11 staff meeting. The overall goal of completion of an aftercare plan for all patients will be discussed. At minimum, all successful discharges will have an aftercare plan completed by discharge. This aftercare plan will be started by the counselor with each patient once they indicate they are stable and wish to begin process of working towards a successful discharge.
The Facility Director will be in charge of making changes in the Aftercare Plan Document and presenting this Plan and how it should be administered in the 8/24 staff meeting. It will be the individual counselors' role to complete these aftercare plans at this time, under the supervision of the Clinical Supervisor. |