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Procedures have not been established to achieve compliance with a recently enacted
statute
Notice of Denial of Admission forms lacked required information
Discharge summaries did contain proper authorization |
FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS
NONCOMPLIANCE WITH STATUTORY MANDATE
The Center has not implemented procedures to ensure compliance with one of its
statutory mandates.
State law requires the Center to advise its recipients (patients) of the circumstances
under which the law permits the use of emergency forced medication, restraints or
seclusion. At the same time, the facility should inquire of the patients which form of
intervention the patient would prefer if any of these circumstances should arise. The
preference is to be noted in the record and communicated by the Center to the patient's
guardian.
During our review of files and through discussion with Center personnel, we noted that
there were no procedures in place to implement this statute. (Finding 2, page 11)
Center personnel accepted our recommendation to implement policies to ensure compliance
with this statute.
LACK OF PATIENT FILE DOCUMENTATION
The Center had missing and incomplete documentation in patient files. Below is a
summary of the audit exceptions:
- Of 10 files tested, we noted numerous problems with the Notice of Denial of Admission
form. Forms lacked required information and the facility director's signature.
Additionally, one form was not located in the patient file.
- Two of six patients were not notified in writing 7 days prior to the Medication
Treatment Review Panel Meeting.
- Four of 25 patient files did not contain proper authorization by the Center director on
discharge summaries.
- One of three deceased patient files had a missing Notice of Death form and one had an
incorrect date of mailing the notice to the Department of Public Health. (Finding 3, pages
13-14)
We recommended that the Center implement internal controls necessary to ensure that
accurate and complete information is maintained in patient files. The Center accepted this
recommendation, stating management will reinforce internal controls necessary to identify
and monitor for accuracy, completeness, timeliness and inclusion of required documentation
in patient files.
OTHER FINDING
The remaining finding dealt with untimely annual evaluations. We will review
progress toward implementation of all recommendations during the next audit.
AUDITORS' OPINION
We conducted a compliance audit of the Center as required by the Illinois State
Auditing Act. We also performed certain agreed upon procedures with respect to the
accounting records of the Center to assist our financial audit of the entire Department.
Financial statements for the Department will be presented in that report.
____________________________________
WILLIAM G. HOLLAND, Auditor General
WGH:KMC:ak
SPECIAL ASSISTANT AUDITORS
Our special assistant auditors were McGladrey & Pullen, LLP.
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