Observations
Based on the review of patient records, the facility failed to ensure the psychosocial evaluations contained a clinical assessment of the historical data collected in two of five patient records.
The findings include:
Eight patient records were reviewed February 21, 2012. Five patient records were reviewed for psychosocial evaluations.
Patient # 2 was admitted December 23, 2011. The psychosocial evaluation documentation consisted of statements relating what the patient reported and what the patient identified and did not evaluate this information.
Patient # 5 was admitted November 16, 2011. The psychosocial evaluation documentation consisted of statements relating what the patient reported and what the patient stated and did not evaluate this information.
This was counselor specific. This is a repeat deficiency from the August 2011 methadone inspection.
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Plan of Correction
Meeting was held between the Clinical Supervisor and the specific counselor involved in this deficiency and the counselor was instructed on the proper completion of the psychosocial evaluation to not document patient reports but to be documented from an evaluative information perspective by the counselor. Clinical Supervisor will monitor compliance during clinical supervision. Completed date 3/5/12 |