Observations
Based on a review of agency policy and procedure, client records and an interview with the clinical supervisor, the facility failed to discharge clients who have not attended treatment in 30 days, and inform them of such discharge as per agency policy, in four of four client records.The findings include:Eleven outpatient client records were reviewed on July 1, 2010. Four of the clients reviewed did not attend treatment in 30 days or more, and per agency policy should have been discharged and provided with notice of such discharge. The facility failed to document a 30 day discharge letter and/or treatment closure in client records # 4, 6, 7 and 8.Client # 4 was admitted on February 22, 2010 and was last seen on May 10, 2010. There was no documentation of a discharge letter and the client's treatment experience remains open as of July 1, 2010.Client # 6 was admitted on December 3, 2009 and was last seen on May 13, 2010. A discharge letter was mailed on June 24, 2010 stating that the client would be discharged on July 8, 2010. The discharge summary was not completed within 30 days of the last day seen.Client #7 was admitted on January 22, 2010 and was last seen on May 14, 2010. There was no documentation of a discharge letter; however, the client was discharged on June 22, 2010. The discharge summary was not completed within 30 days of the last day seen.Client #8 was admitted on April 7, 2010 and was last seen on May 7, 2010. There was no documentation of a discharge letter; however, the client was discharged on June 22, 2010. The discharge summary was not completed within 30 days of the last day seen.An interview with the clinical supervisor took place on July 1, 2010 at which time it was confirmed that the agency discharge policy was not being followed in the aforementioned client records.
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Plan of Correction
The Clinical Supervisors will meet with all staff in individual supervision to review the policy and procedures for the discharge of clients who have not attended treatment for 30 days and informing clients of such discharge. The due dates and processes for each will be included in the individual training session. Review of the procedure will also be included in the clinical staffings in August and September. It shall be the responsibility of the Clinical Supervisor to ensure remediation and compliance with this regulation through weekly chart audits and ongoing supervision. Further, the Clinical Supervisor will conduct a review of discharged cases to assure the standards are being met. |
Observations
Based on a review of agency policy and procedures, client records and an interview with the clinical supervisor, the facility failed to document treatment plan updates within sixty days, as per agency policy and regulation in six of eight client records.The findings include:Eleven outpatient client records were reviewed on July 1, 2010. Eight client records required treatment plan review and updates. Per the facility policy and regulation, treatment plan review and updates are required to be completed every sixty days. The facility failed to document treatment plan review and updates within sixty days, in client records # 3, 4, 5, 7, 8 and 9.In client record # 3, the client was admitted on October 27, 2009. The comprehensive treatment plan was completed on November 13, 2009. The first treatment plan update was due no later than January 13, 2010 and was not completed until January 20, 2010. The second treatment plan update was due no later than March 13, 2010 and was completed on March 20, 2010. The third treatment plan update was due to be completed on May 13, 2010 and was completed May 27, 2010.In client record # 4, the client was admitted on February 22, 2010. The comprehensive treatment plan was completed on April 9, 2010. The first treatment plan update was due no later than June 9, 2010. The facility failed to document the completion of the first treatment plan update as of July 1, 2010.In client record # 5, the client was admitted on November 17, 2009. The comprehensive treatment plan was completed on December 10, 2009. The first treatment plan update was due no later than February 10, 2010 and was completed on March 10, 2010. In client record # 7, the client was admitted on January 22, 2010 and discharged on June 22, 2010. The comprehensive treatment plan was completed on January 22, 2010. The first treatment plan update was due no later than March 22, 2010 and was completed on March 26, 2010. The second treatment plan update was due no later than May 22, 2010. The facility failed to document the completion of the second treatment plan update as of July 1, 2010.In client record # 8, the client was admitted on April 7, 2010 and discharged on June 22, 2010. The comprehensive treatment plan was completed on April 7, 2010. The first treatment plan update was due no later than June 7, 2010. The facility failed to document the completion of the first treatment plan update as of July 1, 2010.In client record # 9, the client was admitted on September 24, 2009 and discharged on January 14, 2010. The comprehensive treatment plan was completed on October 15, 2009. The first treatment plan update was due no later than December 15, 2009 and was not completed until January 7, 2010. An interview with the clinical supervisor took place on July 1, 2010 at which time it was confirmed that the treatment plan updates in the aforementioned client records were not documented as per policy and regulation of every sixty days.
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Plan of Correction
The Clinical Supervisor will meet with all staff in individual supervision to review the policy and procedures for completing treatment plans within required timeframes. The due dates and processes will be included in the individual training session. Review of the procedure will also be included in the clinical staffings in August and September. It shall be the responsibility of the Clinical Supervisor to ensure remediation and compliance with this regulation through weekly chart audits and ongoing supervision. |