Observations
Based on a review of a patient record and the Corporate Compliance Policy regarding documentation, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for patients.
Per the Corporate Compliance Policy, documentation of services will be completed within 48 business hours of the service. Corrections, additions or other changes to clinical documentation must be recorded as an Addendum with dated signature.
Patient # 1 was admitted on September 22, 2025, and was still active at the time of this investigation. There were two notes, titled Note to File, put into the patient record and dated August 11, 2026. One note indicated it was from a meeting with the patient on May 26,2026, and the second note indicated it was from information received on June 15, 2026.
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Plan of Correction
On August 26, 2026, the Facility Director met with the practitioner responsible for the late documentation. The practitioner received a reminder of the Corporate Compliance Policy requirement for accurate documentation of patient encounters within 48 business hours and on the use of the Addendum function for any corrections or additions entered outside the required timeline. All clinical staff will be reminded of documentation timeliness, addendum requirements, and DDAP standards. The practitioner was provided a physical copy of the Corporate Compliance Policy for reference. Ongoing compliance with the regulation will be the responsibility of the Clinical Supervisor through random monthly audits of clinical documentation to ensure that clinical documentation meets agency timelines and policies. |