Observations
Based on interviews and review of the patient records, the facility failed to document a physicians signature on treatment plans and treatment plan updates in five of five records reviewed.
The findings include:
Nine patient records were reviewed on June 9, 2011. Four patient records were not applicable to the regulation. Of the remaining five records, five records were medical assistance or community behavioral health funded patients which require a physician signature on the treatment plans and the treatment plan updates. Physician signatures were not documented on the treatment plans and treatment plan updates in client records # 1, 2, 3, 4, and 5
Patient record #1 -Patient admitted to treatment on March 24, 2011. The comprehensive treatment plan failed to include documentation of a physician's signature on June 9, 2011
Patient record #2 - Patient admitted to treatment on March 3, 2011. The comprehensive treatment plan failed to include documentation of a physician's signature on the comprehensive treatment plan and the treatment plan update on June 9, 2011.
Patient record #3 - Patient admitted to treatment on December 2, 2010. The comprehensive treatment plan failed to include documentation of a physicians signature and the treatment plan updates of March 2011 and May 2011 also failed to include documentation of a physician signature on June 9, 2011.
Patient record #4 - Patient admitted to treatment on March 17, 2011. The comprehensive treatment plan failed to include a physician's signature on June 9, 2011.
Patient record #5 - Patient admitted to treatment on February 14, 2011 and discharged on March 22, 2011. The comprehensive treatment plan failed to include a physician's signature on June 9, 2011.
In and interview with the outpatient director on June 9, 2011, it was confirmed the physician signatures were not documented for patients funded by medical assistance or through the Community Behavioral Health System. An interview with the facility physician and quality assurance director verified a physician attends a case consultation that is conducted in coordination with the plan updates, however, the physician does not sign-off on the treatment plan update.
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Plan of Correction
The software for the Marworth electronic medical record (EMR) had not considered physician signature on the treatment plan or treatment plan update when developed. Necessary changes to the software have been completed by the Information Technology Director of Marworth to the EMR and Physician signatures are now recorded on treatment plans and treatment plan updates for medical assistance clients. |