Observations
Based on a review of four detox client records, the facility failed to adhere to its " Requirements for Completion of Treatment " procedure. This procedure notes " ... patient has medically stabilized and detox staff feel that it is medically safe to discharge patient to the next LOC. "
Patient #3 was admitted to detox on April 28, 2026, and was transferred to residential on May 3, 2026. There was no documentation in the client record to verify that this client was medically cleared to be transferred to residential treatment.
Patient #4 was admitted on May 15, 2026, and was transferred to residential on May 21, 2026. There was no documentation in the client record to verify that this client was medically cleared to be transferred to residential treatment.
These findings were reviewed with the facility staff during the complaint investigation.
|
Plan of Correction
The facility has reviewed and revised its transfer and discharge documentation process to ensure compliance. Effective immediately, the attending medical provider will complete and document a medical clearance note in the client's EMR. The documentation will clearly indicate that the client has been medically assessed, is medically stable, no longer requires detoxification services, and is appropriate for transfer. The Medical Director and Clinical Director will conduct routine audits of records to verify that all transfers include documented medical clearance by the medical provider. Any identified deficiencies will be communicated to the COO and addressed immediately through correction action, education, and ongoing performance monitoring to ensure continued compliance. |