State cites Poplar Springs' Military Program for incomplete medical records and treatment plans

Poplar Springs Hospital’s Military Services program was cited by the Virginia Department of Behavioral Health and Developmental Services (DBHDS) for deficiencies related to documentation and record keeping. Virginia standards require entries in patient medical records “shall be current, dated and authenticated by staff making entries.” During a records review of Poplar Springs Hospital’s Military Services Program, DBHDS found “inconsistencies of staff appropriately dating and signing various documents within the records.” In one example cited by DBHDS, an individual had a daily activities tracking sheet that did not have a signature for evening wrap up group and did not have a date/time for morning goal setting group. Because neither of the records were correctly completed, it was unclear to inspectors whether the individual set morning goals and/or participated in evening group. Another individual had two master treatment plans in his/her medical record. The first treatment plan was incomplete and contained blanks in the diagnosis, problem list, discharge, and preliminary sections and the second plan was also incomplete. DBHDS inspectors noted that it “cannot be determined what goals and objectives are being addressed.” The program submitted a plan of correction to address these cited deficiencies.