Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable client records reviewed.
The facility's policy and procedure manual stated the emergency contact will be notified within 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Client #5 was admitted on March 24, 2024 and was discharged against medical advice on April 1, 2024. There was no documentation, in the record, indicating the emergency contact was notified upon discharge of the client as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Social Services/Case Management will provide re-education to all inpatient case managers about making outreach to approved emergency contacts when a patient leaves the facility against medical advice. Re-education will occur by 11/22/2024.
The Director of Social Services/Case Management or a delegate will audit 100% of AMA discharged records to monitor for compliance. Audits will begin 11/11/2024 and continue until 90% or above compliance is reached for three consecutive months.
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