Observations
Based on the review of patient records, the facility failed to complete annual evaluations in accordance with the regulations in one of six patient records reviewed.
The findings included:
Ten patient records were reviewed on April 15, 2010. Four patient records were reviewed for completion of an annual evaluation of the patient's status. The facility did not document an annual evaluation for patient # 6.
Patient #6 was admitted on January 14, 2005. The most recent annual evaluation was due to be completed by January 14, 2010. There was no documentation in the record that an annual evaluation had been completed as of April 15, 2010.
An interview with the clinical supervisor on April 15, 2010 confirmed that the January 14, 2010 annual evaluation was not completed.
|
Plan of Correction
The program director will ensure, through quality assurance chart review and direct supervision that annual evaluations are completed in accordance with regulations.
Under the direction of the program director, the nurse coordinator of the program will, at the beginning of each month, run a report that lists all clients who are due for an annual evaluation that month and on what date. The nurse coordinator will provide each clinical supervisor with the list and the supervisors will, in turn, notify the individual therapists.
Under the direction of the program director, the nurse coordinator will educate clinical supervisors that the due date of the annual evaluation on the monthly list is the correct due date that the therapists should follow, despite what date was noted on the prior annual evaluation. The prior evaluation could have been completed late and therefore would reflect a skewed date.
Under the direction of the program director, at the end of each month the clinical supervisors will complete an audit to ensure that all annual evaluations have been completed and signed the medical director for that month.
The above information will be shared with program management during a management meeting on May 24, 2010 and with clinical staff during a clinical team meeting on May 25, 2010.
|