Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against facility advice in one of one applicable record.
The facility's policy and procedure manual states the client ' s emergency contact will be notified within 12 hours of the client ' s decision to leave against facility advice, providing there is consent given in writing to contact the emergency contact.
Client #3 was admitted on May 23, 2024, and discharged on June 28, 2024. There was a consent for the emergency contact in the client record but no documented attempt to contact emergency contact following discharge.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Program Director informed all program staff of licensing review results and reminded staff of the requirement to notify an emergency contact on record when a client leaves treatment against staff advice within 12 hours. Program Director reminded staff that an incident report must be completed within 24 hours from when a client leaves against staff advice and that notifying the emergency contact must be documented in this report as well. Program Director educated staff on using the new "Note to Chart" document in the electronic health record to document when an emergency contact is notified that a client left treatment against staff advice. This information was reviewed again by the Program Director during the staff meeting held on 8/29/2024.
Person(s) Responsible: Program Director
Target Completion Date: Completed 8/8/2024 and 8/29/2024
2. Clinical Supervisor and Recovery Support Supervisor updated discharge checklist for staff reference to include reference to the "Note to Chart" to document specifically when an emergency contact is notified after a client leaves treatment against staff advice.
Person(s) Responsible: Clinical Supervisor, Recovery Support Supervisor
Target Completion Date: Completed 8/28/2024
3. Program Director will reject any agency incident reports for a client leaving against staff advice that are submitted without information related to contacting the emergency contact.
Person(s) Responsible: Program Director
Target Completion Date: Ongoing
4. Program Director and other supervisors will document information and directives given about completing incident reports in their entirety and/or contacting emergency contacts when a client leaves treatment against staff advice in supervision notes, memos, and staff meeting minutes.
Person(s) Responsible: Program Director, Clinical Supervisor, Recovery Support Supervisor
Target Completion Date: Ongoing
5. Program Director provided all staff with a copy of the Gaudenzia "PA 3.5 Workflow" (revision date 6/30/2024) which references requirements when a client leaves treatment against staff advice.
Person(s) Responsible: Program Director
Target Completion Date: Completed 9/4/2024
6. Clinical Supervisor, Program Director, and CQI Manager will seek documentation of notification of an emergency contact within 12 hours when a client leaves treatment against staff advice and ensure that staff document that the notification was made during monthly/quarterly CQI chart audits. Clinical Supervisor and Recovery Support Supervisor will utilize supervision and performance improvement plans to address documentation deficiencies.
Person(s) Responsible: Clinical Supervisor, Program Director, CQI Manager, Recovery Support Supervisor
Target Completion Date: Ongoing |