Observations
Based on a review of client records and the Admission Criteria policy, the facility failed to follow its procedures for physical examinations.
The Admission Criteria policy indicates the client is to be seen by the medical doctor for a physical examination within 72 hours of admission.
Client # 1 was admitted on 2/16/24 and discharged on 4/1/24. The physician assessment was due no later than February 19, 2024. The physician assessment was dated 2/22/24.
Client # 3 was admitted 2/16/24 and completed 4/5/24. The physician assessment was due no later than February 19, 2024. The physician assessment was dated 2/20/24.
|
Plan of Correction
On 9/13/24, policy number: IASAR6 Admission Criteria was updated to state as follows: 6) Following the intake session, the client will be assigned a bed and provided orientation to the program. Orientation to the program will begin on the day of the admission. In orientation, a staff person conducts a brief tour of the floor to orient the client to the facility. The nurse or designate completes a medical history and the client is seen by the medical doctor for a physical examination, preferably within 72 hours of admission, but no later than 7 days after admission. Medical staff (nurse and provider) will be educated on the policy update and the timeframe for completion of physical examination with in the first 7 days, preferably in 72 hours. The SUD Director will complete weekly chart audits to ensure new clients have been seen by provider for physical exam in this time frame. SUD Director will meet with nurse every Tuesday Morning to confirm all new clients are on the doctors appointment schedule for that day. |