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32 | CONTINUED FROM FORM LIC9099
All records reviewed on the facility's electronic records platform were verified to include all necessary elements of documentation such as the name of client, birthdate, sex, Last known address, Date of admission, Name, address, and telephone number of the client's authorized representative(s), if any, a signed copy of the admission agreement (...), name, address and telephone number of the client's physician and dentist, and other medical and mental health providers, if any, Medical assessment, including ambulatory status, as specified in Section 81069, Record of any illness or injury requiring treatment by a physician or dentist and for which the facility provided assistance to the client in meeting his/her necessary medical and dental needs, Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications, documentation of any Restricted Health Condition Care Plan, if required for the client (...), a functional assessment (...), religious preference, and name and address of clergyman or religious advisor, if any, needs and services plan and any modifications thereto, (...), an account of the client's cash resources, personal property, and valuables entrusted (...) as well as the date of termination of services.
As a result, the allegation that Client file records are missing and/or incomplete is found to be Unsubstantiated, meaning that Although the allegation(s) may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation did or did not occur.
An exit interview was conducted and a copy of this report was provided to a facility representative. |