Observations
Based on a review of client records during a complaint investigated conducted on June 13, 2023, the facility failed to ensure a complete client record.A discharge summary was missing in two out of the four charts reviewed.Client #2 was admitted on 1/17/2023 and was discharged on 1/23/2023. The client was readmitted on 1/29/2023 and was discharged on 2/17/2023. The client chart was missing the discharge summaries.Client #3 was admitted on 3/5/23 and discharged 3/11/23. The client chart was missing the discharge summary.This was discussed with facility staff during the investigation.
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Plan of Correction
To improve quality of care and to re- establish compliance, the Mt. Laurel Recovery Center Director of Quality Improvement will complete re-education with the clinical services department staff by 6/30/23 on regulation 709.53 regarding the completion of a discharge summary for all clients. The referenced cited charts will be corrected and have discharge summaries completed by the Clinical Director. To ensure long-term sustainability, the Clinical Director will complete an audit of 100% of discharged medical records per month to ensure post discharge summaries are completed with a goal of 100% compliance per month. Audits will take place until 100% compliance is sustained for 6 consecutive months. Oversight of compliance will be monitored quarterly by the Committee of the Whole. In the event non-compliance is identified, the clinician will be re-educated and/or receive appropriate disciplinary action. |