Observations
Based on a review of the patient records, the facility failed to document the signature of the medical director on the annual evaluation in two of the five records reviewed, and complete one annual evaluation in one of five records reviewed.The findings include:Eleven patient records were reviewed on January 16 -17, 2014. Five of the eleven patient records are required to include an annual evaluation. Three of the five records failed to complete or include the medical directors signature on the annual evaluation. Patient record # 4 was admitted to treatment on October 26, 2012. The annual evaluation was completed on October 23, 2013. The evaluation was signed by the narcotic treatment physician, but was not signed by the medical director as required.Patient record # 10 was admitted to treatment on September 28, 2012. The annual evaluation was completed on September 25, 2013. The evaluation was signed by the narcotic treatment physician, but was not signed by the medical director as required.Patient record # 11 was admitted to treatment on March 10, 2010. The annual evaluation was due by March 10, 2013. The annual evaluation not documented.The findings were reviewed with the project director and the clinical supervisor and were not disputed.
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Plan of Correction
All annual evaluations will be signed by the Medical Director. The paper will be changed to denote Medical Director signature and not Physician signature. |