Observations
A review of ten client records was conducted on February 1, 2017. Based on this review, the facility failed to ensure a physical examination that was completed was signed by a physcian in clients records #2 and 4.
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Plan of Correction
On 2/27/2017 the Case Manger responsible for intakes was trained regarding the need to have a physician sign off on the medical form and not a nurse in accordance with standard 709.52. Going forward the Case Manger will submit all referral paperwork to the Director prior to accepting the client for review of proper medical documentation. Monitoring will continued for 2 months (until 5/13/2017). Then random monitoring by the director will continue on a quarterly basis.
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