Observations
Based on the review of patient records, the facility failed to document the attempt or completion of patient follow up contact in six of eight patient records reviewed.
The findings include:
Ten patient records were reviewed July 8, 2014. Eight patient records required documentation of an attempt or completion of a follow up contact. Per the facility's policy, if the patient is referred to another agency, within seven business days following the patient's continuing care appointment, staff will attempt to contact the provider to determine if the patient attended the scheduled appointment. The facility will attempt to contact all other discharged patients within 30 business days after discharge. The documentation is placed in the patient's medical record.
Patient # 3 was admitted on March 23, 2014 and discharged on March 24, 2014. The follow-up contact was to have been made within 30 days of discharge. There was no follow-up documented at the time of the inspection.
Patient # 4 was admitted on April 21, 2014 and discharged on April 26, 2014. The follow-up contact was to have been made within 30 days of discharge. There was no follow-up documented at the time of the inspection.
Patient # 5 was admitted on February 3, 2014 and discharged on February 8, 2014. The follow-up contact was to have been made within 30 days of discharge. There was no follow-up documented at the time of the inspection.
Patient #6 was admitted on January 25, 2014 and discharged on January 29, 2014. The follow-up contact was to have been made within 30 days of discharge. There was no follow-up documented at the time of the inspection.
Patient #8 was admitted on May 29, 2014 and discharged on June 4, 2014. The follow-up contact was to have been made within 30 days of discharge. There was no follow-up documented at the time of the inspection.
Patient #10 was admitted on April 21, 2014 and discharged on April 26, 2014. The follow-up contact was to have been made within 30 days of discharge. There was no follow-up documented at the time of the inspection.
An interview with the facility director on July 8, 2014 confirmed the findings.
This is a repeat citation. The facility was previously cited for noncompliance with this standard.on July 2, 2013.
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Plan of Correction
Staff involved in the completion of follow up contacts were re-trained by the Facility Director during the month of July 2014. All nursing and clinical staff are responsible for completing follow up forms and submitting those forms to the administrative staff for completion of the follow up contacts. A log is maintained in by the administrative staff with all clients discharged from the facility to ensure that follow up forms are recieved on every client. The Medical Secretary was also trained on the follow up policy and procedure and will conduct chart audits within 7 days of discharge to ensure follow up contacts are documented on all discharges. If a follow up form is noted to be missing from the chart by the administrative staff or medical secretary, the form will be completed immediately by the staff that noted the deficiency and the follow contact will be made by the administrative staff. |