Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in three of seven client records.
Client #1 was admitted on October 14, 2020 and is currently an active client. There was no psychosocial evaluation documented in client record #1.
Client #2 was admitted on November 23, 2020 and is currently an active client. There was no psychosocial evaluation documented in client record #2.
Client #7 was admitted on October 19, 2020 and discharged on March 2, 2021. There was no psychosocial evaluation documented in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our BioPsychoSocial form is a required part of our opening paperwork. Beginning March 5, 2021, the facility director will review the charts of all newly opened clients each week to ensure that a properly completed and signed biopsychosocial form is in each client's chart. |