Observations
Based on a review of client records, the facility failed to document the date of completion of the discharge summary in one of four client records reviewed and failed to document the discharge within the time frame in one of four client records.
The findings include:
Ten client records were reviewed on December 7, 2010. Discharge summaries were required to be documented in four of the client records. Discharge summaries are required to be documented within one week of discharge. One of two discharge summaries, client record # 7, did not include documentation of the completion date, therefore, it is unable to be determined if they were completed within the one week time frame. One of the two discharge summaries, client record #10, was not completed within the one week time frame.
Client #7 was admitted on August 27, 2010 and discharged on September 24, 2010. The discharge summary was due by October 1, 2010. The discharge summary was documented, but it did not include a signature, or the date it was completed.
Client #10 was admitted on May 25, 2010 and discharged on June 18, 2010. The discharge summary was due by June 25, 2010. The date it was completed was 12-6-10. The discharge summary was documented, but it was completed late.
The facility director confirmed on December 7, 2010 that one discharge summary did not have the date of completion documented, and one discharge summary was completed late.
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Plan of Correction
Discharge summaries will be completed and dated within one week of client's discharge from the program. This will be monitored by the Program Supervisor and Program Director, as well as the Division Director through the monthly QI/PI process. |