Observations
Based on a review of a client's record on April 10, 2026, the facility failed to document a discharge summary within 7 days of the client ' s discharge.
Client #1 was discharged on September 25, 2025, and the discharge summary was not completed until October 23, 2025. There was no documentation in the client's record stating the reason the discharge summary was completed late.
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Plan of Correction
The facility's current policy regarding discharge summary documentation has been reviewed and determined to be current and appropriate. Clinical staff will receive training on the existing discharge summary policy, including expectations related to completion timelines, specifically the requirement that discharge summaries be completed within seven (7) days. This training will be conducted on 5/21/26 and will include all applicable clinical staff.
The Clinical Supervisor will monitor staff adherence to this policy for a period of six months to ensure ongoing compliance. Failure to comply with the facility's documentation policy and established timelines may result in corrective or disciplinary action in accordance with facility procedures. |