Observations
Based on a review of client records, the facility failed to document a discharge summary within seven days of discharge in three of nine client records.
The findings include:
Nine discharged client records were reviewed on April 1-3, 2013. A discharge summary, which is to be completed within seven days of discharge, was required in all nine client records. The facility did not document a discharge summary within seven days of discharge in client records # 1, 4 and 22.
Client #1 was admitted to treatment on January 31, 2013 and discharged on February 27, 2013. A discharge summary was due to be completed by March 6, 2013. The discharge summary was completed on March 28, 2013.
Client #4 was admitted to treatment on June 18, 2012 and discharged on March 18, 2013. A discharge summary was due to be completed by March 25, 2013. The discharge summary was completed on April 1, 2013.
Client #22 was admitted to treatment on February 14, 2012 and discharged on March 18, 2013. A discharge summary was due to be completed by March 25, 2013. The discharge summary was completed on March 28, 2013.
An interview with the clinical supervisor took place on April 3, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
All documentation of patient records for discharge will be reviewed by the Director of Social Services or the Assistant Director of Social Services on a weekly basis to monitor compliance with the timeliness of the completion of the discharge summary. This review will begin effective April 8, 2013. |