INITIAL COMMENTS
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This report is a result of complaint investigation conducted on July 28, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the following deficiencies were identified during this inspection.
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Plan of Correction
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709.62(a)(4) LICENSURE Criteria - Discharge/termination
709.62. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on the review of administrative documentation, client records, and an interview with the facility director, the facility failed to follow their policy for clients that want to leave against facility advice.
The findings include:
The staff communication log and client record # 1 were reviewed on July 28, 2011. An interview with the facility director indicated that it is the practice at the facility to allow a client that wants to leave against facility advice to have a phone call prior to discharge if they are not being disruptive or unruly. After a review of the client's record and the communication log it was determined that there was no indication that this client should have been denied a phone call prior to discharge. The record did not provide documentation regarding the discharge of this client other than a form that was signed by the client indicating that he was leaving against medical advice. There was no documentation that this client was afforded a phone call prior to discharge.
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Plan of Correction
The Program Director and Program Supervisor reviewed with all staff the discharge policy and protocols for clients seeking to leave treatment against medical advice. Additionally a memo was issued to all staff clarifying step by step procedures.
The memo indicates that any phone call made by a client prior to discharge shall be documented on the daily client phone call log or in the client record.
The Program Director and Program Supervisor will monitor ongoing conformance during monthly audits.
Target Resolution Date: 8/12/11
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709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document a complete history on the client.
The findings include:
Three client records were reviewed on July 28, 2011. Client record #1, the record of the complainant, failed to have a history documented in the client record. An interview with the facility director confirmed this finding.
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Plan of Correction
On 8/2/11, the Program Director met with all nursing personnel to review the facility policies, protocols, and licensing requirements for completion and documentation of a complete history on all clients admitted to detoxification services.
The Program Supervisor met with all clinical personnel to review the facility policies, protocols, and licensing requirements for completion and documentation of a complete history on all clients admitted to rehabilitation services.
A nightly record review will be completed by nursing personnel to assure that all histories are completed as required. Histories needing completion will be listed on the Nurse's Communication Board for prompt attention.
The Program Director and Program Supervisor will monitor ongoing conformance of client history documentation during monthly record audits.
Target Resolution Date: 8/12/11 |