Observations
Based on a review of client records, the facility failed to document follow up contact within 15 days of discharge and/or AMA discharge contact within 12 hours of discharge, as per facility policy, in 3 of 7 client records.
Client #2 was admitted on August 11, 2022 and left the facility against medical advice (AMA) on August 12, 2023. There was no documentation of AMA discharge contact or follow up contact in client record #2.
Client #6 was admitted on January 30, 2023 and discharged for completion on February 1, 2023. There was no follow up contact documented in client record #6.
Client #7 was admitted on November 16, 2022 and discharged against medical advice (AMA) on November 19, 2022. There was no documentation of AMA discharge contact in client record #7.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the June 16, 2022 annual licensing inspection.
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Plan of Correction
All staff will be re-educated on need to
contact all detoxification clients by completing a follow up contact within 15 days of discharge and/or AMA discharge contact within 12 hours of discharge, as per facility policy. This will be completed by a re-education for all staff which will be conducted to include education on the AMA Policy as well as the Aftercare policy.
Staff will be required to sign stating that they have participated in the education and/or read the information regarding these policies and agree to follow the policy. The education will specifically include the importance of documenting the calls in the Electronic Medical record. This education will be completed no later than 7/31/23.
An audit of the electronic medical record for completed detox patients will occur Bi-monthly by the lead counselor and AMA discharge calls will be audited within 24 hours of the AMA discharge by lead counselor. This audit will include the calls being made and charted in the Electronic Medical Record according to the policy.
Any deficiencies noted will be address in clinical supervision. During this review any detox patients that were not called within the time frame of the policy, will be called and followed up on in real time and this will be documented in the Electronic Medical Record. |