Observations
Based on a review of client records, the facility failed to follow their policy for notifying emergency contacts when an individual leaves treatment against medical advice to comply with Act 41 of 2021.
Client #5 was admitted on January 20, 2022, but left treatment against medical advice on February 21, 2022. Client record #5 contained a valid release of information to an emergency contact, but the client record did not include documentation that the emergency contact was notified when the client left treatment.
Client #6 was admitted on March 28, 2022, but left treatment against medical advice on March 31, 2022. Client record #6 contained a valid release of information to an emergency contact, but the client record did not include documentation that the emergency contact was notified when the client left treatment.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clem-Mar House will follow guidelines in our policy and procedures manual to remain in compliance with DDAP Licensing Alert 02-21 relating to Act 41. Our policy states the following: Act 41 requires that inpatient drug and alcohol treatment facilities must immediately notify an emergency contact if a patient leaves the facility against medical advice, provided the patient has not revoked consent to notify the emergency contact if one is on file. The Clem-Mar House Inc. will make notification immediately and in no event later than 12 hours of a patient leaving against medical advice. Notification to the emergency contact will be made by the method consented to by the patient, stated on their release of information.
Upon admission into the facility, a resident is asked to sign a release of information for an emergency contact. The resident is notified of contact if they choose to leave AMA. When leaving the facility against medical advice, a resident is again made aware of the policy to contact one's emergency contact, as stated when signing the AMA document. Staff makes a record of this by logging this the contact on the Facilities' Family Record of Service located in the Clinical Section of the resident chart. This contact is also documented on the Discharge Summary.
Our facility will not make notifications when the facility has knowledge of, or reason to know of allegations of domestic abuse perpetrated upon the patient by the patient's designated emergency contact.
A staff meeting conducted by the Facility Director took place on 05/05/2022. This meeting reviewed the importance of following our policy to remain compliant with Act 41. Both clinical and support staff are understating and will remain in compliance.
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