Observations
Based on a review of client records, the facility failed to document follow-up attempts in five of the six client records.
The findings include:
On August 1, 2012, nine client records were reviewed. Six of the nine client records were required to include documentation of follow-up attempts. The facility failed to document follow up attempts in five of the six client records, specifically client records #2, #3, #4, #7, and #9. The facility follow-up policy states that the client will be contacted via telephone one week following discharge, and documentation will be noted in the client record.
Client #2 was admitted on 3-13-12 and discharged on 6-7-12. The follow up attempt was due by 6-14-12. There was no documentation of attempts to follow up on the client.
Client #3 was admitted on 1-23-12 and discharged on 7-3-12. The follow up attempt was due by 7-10-12. There was no documentation of attempts to follow up on the client.
Client #4 was admitted on 2-8-12 and discharged on 6-11-12. The follow up attempt was due by 6-18-12. There was no documentation of attempts to follow up on the client.
Client # 7 was admitted on 4-23-12 and discharged on 7-5-12. The follow up attempt was due by 7-12-12. There was no documentation of attempts to follow up on the client.
Client #9 was admitted on 4-2-12 and discharged on 6-7-12. The follow up attempt was due by 6-14-12. There was no documentation of attempts to follow up on the client.
The findings were reviewed with the project director and the clinical director and were not disputed.
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Plan of Correction
Effective 8/9/12 the Gaiser Center created a new position, Clinical Lead of Outpatient Treatment and appointed a Masters Level CADC, LPC to fill the role. The OP Clinical Lead is responsible for ensuring that all treatment policies are adhered to, including the IOP/OP follow up call. The Clinical Lead reviewed with all OP counselors the Gaiser Center policy mandating that an attempt be made to contact all clients regardless of discharge type in approximately seven days from discharge and document the outcome. Effective 8/9/12 all client follow up calls are being made by the counselor and the outcome is documented. |