Observations
Based on the review of client records, the facility failed to document a complete client record to include progress notes.
The findings include:
Eight client records were reviewed for documentation of progress notes for individual sessions on September 5, 2013. The facility failed to document individual progress notes in three out of eight client records reviewed, specifically client records # 3, 4, and 5.
The findings include:
Client # 3 was admitted on May 13, 2013 and was still active during the time of inspection. The record of services for client #3 documented individual sessions had occurred on 6/6/13, 6/13/13, 6/20/13, and 7/11/13. As of the date of inspection, there was no documentation of these progress notes for client # 3.
Client # 4 was admitted on April 2, 2013 and was still active during the time of inspection. The record of services for client #4 documented individual sessions as having occurred on 5/13/13, 5/20/13, 5/30/13, 6/5/13, 6/10/13, 6/17/13, 6/28/13, 7/1/13, 7/22/13, and 7/31/13. As of the date of inspection, there was no documentation of these progress notes for client # 4.
Client # 5 was admitted on January 9, 2013 and was discharged on June 4, 2013. The record of services for client # 5 documented individual sessions as having occurred on 2/11/13, 3/11/13, 3/20/13, 3/27/13, 5/1/13, 5/8/13, and 5/22/13. As of the date of inspection, there was no documentation of these progress notes for client # 5.
The findings were reviewed with the facility director prior to the exit interview.
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Plan of Correction
Chances has an electronic records database, and going forward Chances will be utilizing this system to store the record of service and the progress notes. Paper copies will no longer be filed in the client chart. This will eliminate the problem of notes being lost or misfiled. All notes will be readily accessible for auditors either electronically or by printing hard copies from the database, as per their personal preference. This system will be in efect as of today, 9/24/2013. |