Assisted living survey tip—Complete those discharge summaries!
By Doug Beardsley | January 27, 2023 | Assisted living providers
A common correction order issued during assisted living surveys relates to a specific element required in the resident record: a discharge summary. The requirement, found at 144G.43 Subd. 3, requires the following:
The contents of the resident record for a resident who has been discharged, must include a discharge summary, including service termination notice and related documentation, when applicable.
The survey documentation typically reads something like this:
Based on interview and record review, the licensee failed to ensure the resident record included a discharge summary with the required content for one of one discharged resident (R6).
The findings include:
R6's record lacked a discharge summary to include:
- diagnoses;
- allergies;
- treatments and therapies;
- pertinent lab, radiology, and consultation results;
- reconciliation of medications, and;
- a final summary of the resident's status from the latest assessment or review including baseline and current mental, behavioral, and functional status.
What process does your facility have in place to assure the elements of a compliant discharge summary are in place? Whose responsibility is it to complete a discharge summary for residents who are discharged?
Did you find this tip helpful? If yes, have you reviewed our
other survey tips and started to use our free, members-only
assisted living compliance audit tools?
Doug Beardsley | Vice President of Member Services |
dbeardsl@careproviders.org | 952-851-2489