Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document discharge summaries as per their policy.
The findings include:
The policies and procedures manual was reviewed.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of discharge summaries:
" Discharge Summary:
After the client's treatment exit when no additional treatment services are anticipated, the Counselor shall complete the Discharge Summary within one week from discharge. "
Six client records requiring documentation of a discharge summary were reviewed on February 20, 2013. Three out of six client records did not have documentation of a discharge summary, specifically #'s 8, 9, and 11.
Client #8 was admitted into treatment on September 19, 2012 and discharged on December 6, 2012. A discharge summary was due by December 12, 2012 for client #8. As of the date of inspection, there was no documentation of a discharge summary for client #8.
Client #9 was admitted into treatment on August 15, 2012 and discharged on January 4, 2013. A discharge summary was due by January 11, 2013 for client #9. As of the date of inspection, there was no documentation of a discharge summary for client #9.
Client #11 was admitted into treatment on July 31, 2012 and discharged on November 2, 2012. A discharge summary was due by November 9, 2012 for client #11. As of the date of inspection, there was no documentation of a discharge summary for client #11.
The findings were discussed with the clinical director during the exit interview.
This is a repeat citation. The facility was previously cited for noncompliance with this standard on May 23, 2012 and September 20, 2012.
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Plan of Correction
Beginning April 9, 2013, the Program Supervisor along with Administarative staff will review the previous weeks discharges in the weekly adminstrative meeting to ensure discharge summaries are completed per policy. In accordance with program policy, Continuing Care/Transition/Discharge Plan and Summary will be completed within seven days of discharge. Discharge summaries for client #9 and client #11 were completed before the inspection on February 20, 2013, but were misfiled. The discharge summary for client#8 has since been completed. The Program Director will be responsible for oversight of compliance with this standard. |