Observations
The facility failed to document a physical exam in two of seven client records reviewed on December 12, 2018. Client records # 5 and 6 documented physicals completed by a nurse. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to the client's admission, the Administrative Assistant will review the physical documentation provided by the referral source and ensure that it has been completed according to regulation 709.51, which includes a medical doctor's signature. If the documentation of the client's physical is inadequate, a call will be made to the referring source requesting adequate documentation of the client's physical be faxed to LRH. If the documentation provided remains unacceptable, the client will be taken to an outpatient medical facility to have a physical completed and documented, within three days of admission to LRH. Otherwise, if an office appointment with a General Practitioner can be obtained in five days maximum, a client may opt to be seen and have their physical exam performed by a local PCP. The client will obtain documentation of the physical at the time of the office visit and provide it to LRH upon their return from the appointment. The document will be filed in the client's chart. |