Observations
The facility failed to document a physical examination in six of seven client records.
Seven client records were reviewed on February 25, 2019. Client records #1, 2, 3, 4, 6 and 7 did have documentation of a physical examination.
Client #1 was admitted on November 26, 2018.
Client #2 was admitted on October 17, 2018.
Client #3 was admitted on September 11, 2018.
Client #4 was admitted on October 22, 2018 and discharged on February 15, 2019.
Client #6 was admitted on August 7, 2018 and discharged on October 28, 2018.
Client #7 was admitted on April 5, 2018 and discharged on December 12, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients referred from partnering agencies will be asked to provide recent physical documentation. Counseling staff will help each client to schedule a physical examination with a primary care provider within 7 days of admission and document the call and appointment time. Counseling staff will request the client return from the appointment with documentation of the physical examination. If the client fails to return documentation of physical examination, staff will coordinate with physician to obtain documentation. Clinical supervisor will review files monthly and document appropriate paperwork on QA form. |