Observations
Based on the review of client records, the facility failed to document medication records in one of two client records.
The findings include:
Four client records were reviewed on March 26, 2009. Medication records were required in two client records. The facility did not document medication records in client record # 2.
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Plan of Correction
A medical history, including a listing of the client's current medications, is gathered during the intake process. The file that was reviewed on March 26, 2009 failed to specify the current medications that the client was prescribed because the client was not certain of the names of the medications. The Plan of Correction is as follows: The procedure for completing this section of the intake was reviewed with staff in the treatment team meeting on 4/2/2009 by the Program Supervisor. It was translated to staff that all current medications must be documented. If the client refuses to provide this information, that refusal must be documented. If the client is uncertain about his/her current medications, the client is to be directed to provide a list of medications at their next appointment and this is to be documented. The Program supervisor will monitor this when reviewing the psychosocial evaluation summaries. |