Observations
Based on an October 24, 2007 review of client records, the facility failed to document a complete psychosocial evaluation in two of four records, #1 and 4. Psychosocial evaluations were historical rather than evaluative. Assets/strengths were stated in terms of what the client said instead of a clinical evaluation. Support systems noted family and friends, but did not assess how the family and friends would be supportive instead of enabling. Coping mechanisms were what the client stated instead of a clinical evaluation.
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Plan of Correction
Observation # 1871
(Psychosocial Evaluation)
In an effort to correct the non-compliance of the psychosocial evaluation, the Director of Behavioral Healthcare Service has scheduled an in-service training for December 21, 2007, to review all elements of the psychosocial evaluation including but not limited to the client's assets/strengths, support systems, and coping mechanism. In addition, the in-service will address the purpose of the psychosocial evaluation, conceptualization of the case, and the summary of the Client's psychosocial composition based on a clinical perspective.
The Clinical Coordinators will review psychosocial evaluations weekly during clinical supervision with the counselors.
Counselors will review psychosocial evaluations during monthly peer reviews.
A random audit of psychosocial evaluations will be conducted periodically by the compliance team to ensure that counselors are consistently meeting compliance.
Correction Time: 12/21/07
Monitoring ongoing
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