Observations
Based on the review of client records, the facility failed to document physical examinations within the seven day timeframe in two of five client records.
The findings include:
Seven client records were reviewed on April 14, 2009. Physical examinations were required in five client records. The facility did not document in a timely manner physical exams in client record # 2 the physical examination was completed twenty-six days late. In client record # 4 the physical examination was completed by a Registered Nurse and not a qualified medical person.
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Plan of Correction
The Director of Operations met with staff responsible for requesting, scheduling, verifying and maintaining client physicals on 5/6/09.
The director of Operation provided clarification to this process and outlined changes to the policy. All physicals must be received or complteted within seven days of a client's admission. In addition, the physicals must be signed by a doctor or a CRNP. The Executive Assistant was advised of this and directed to pay close attention to the physicals received from other entities and if they are not signed by a qualified medical person to attenpt to a valid signature or schedule a physical if the seven time frame is running out.
The Director of Operations will monitor for compliance. |