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Based on review of documentation and interview it was determined that the facility failed to ensure that the discharge summary for patient #1 was completed.

Findings were:
There was no discharge summary found in the medical record of patient #1. Patient #1 was admitted on 2/12/2016 and discharged on 2/21/2016. On 4/05/2016, (the second day of the survey and 45 days after discharge) the facility was unable to produce a copy of the discharge summary when requested by the surveyor. Review of facility policy entitled; "HIM POLICY 011 DELINQUENT MEDICAL RECORDS" stated under the POLICY section: "It is the policy of the facility to maintain an information management process that supports timely, accurate and complete documentation of medical record data and information for all patients." Under the PROCEDURE section of the policy, the following comment was found: "3.0 A medical record is deemed "DELINQUENT" if it is deficient due to failure to document and authenticate a History and Physical Examination, Psychiatric Evaluation, and/or Discharge Summary 30 days after discharge." In the telephonic exit interview with Chief Executive Officer on 4/05/2016 it was confirmed that the discharge summary for patient #1 was delinquent.

Based on review of documentation it was determined that the facility failed to ensure that the treatment plan for patient #1 was complete.

Findings were:
The treatment plan for patient #1 was not complete. The treatment plan provided to the surveyor for review on April 5th (the second day of the survey) did not have the the "Inventory of Assets, Strengths, Liabilities and Special Needs" portion on page 2 completed. This section contained several areas which could be checked by staff member to document the patient's assets, strengths liabilities and special needs. Patient #1 was admitted on 2/12/2016 and discharged on 2/21/2016, a period of 10 days, and this area on the treatment plan was not completed while the patient was hospitalized . A review of facility policy entitled: "HIM POLICY 004 DOCUMENTATION PROTOCOL" stated: "POLICY: Facility records, reports, charts and documents are to be accurate, truthful and complete. Staff is to document accurately our services provided, patient interactions, and all financial transactions. Every staff who creates or reviews documentation in a medical record, or responds to or implements orders or receives directives contained in a medical record, ensures the medical record complies with this protocol. This duty to ensure accuracy of medical records applies to the entire medical record, not just documentation a staff individually creates, reviews or acts upon."

Based on review of documentation and interview it was determined that the facility failed to ensure that the discharge summary for patient #1 was completed.

Findings were:
There was no discharge summary found in the medical record of patient #1. Patient #1 was admitted on 2/12/2016 and discharged on 2/21/2016. On 4/05/2016, (the second day of the survey and 45 days after discharge) the facility was unable to produce a copy of the discharge summary when requested by the surveyor. Review of facility policy entitled; "HIM POLICY 011 DELINQUENT MEDICAL RECORDS" stated under the POLICY section: "It is the policy of the facility to maintain an information management process that supports timely, accurate and complete documentation of medical record data and information for all patients." Under the PROCEDURE section of the policy, the following comment was found: "3.0 A medical record is deemed "DELINQUENT" if it is deficient due to failure to document and authenticate a History and Physical Examination, Psychiatric Evaluation, and/or Discharge Summary 30 days after discharge." In the telephonic exit interview with Chief Executive Officer on 4/05/2016 it was confirmed that the discharge summary for patient #1 was delinquent.