Observations
Based on a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in one of two applicable client record reviewed.
Per the requirement in Licensing Alert 02-21 and the facility's policy, the emergency contact is to be notified no later than 12 hours after a client is discharged from the facility against medical advice.
Client # 5 was admitted on October 8, 2023 and was discharged against medical advice on October 9, 2023. There was no documentation that the emergency contact was not notified of the client's discharge at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Client # 5 was discharged before our inspection. The Clinical Supervisor will complete weekly chart audits to ensure documentation is within compliance and completed on time. Training will be held on or before 2/8/24 with all Detox personnel regarding AMA protocols and documentation. Also, upon hire all staff will be trained regarding all AMA protocols. The COO and Director of Residential Services will ensure the emergency contact is being contacted
within 12 hours by addressing all AMAs during our daily morning and monthly performance improvement meetings. |