Observations
Based on observation, at the time of the project's annual licensing inspection, the facility failed to provide the Department licensing representatives with the plan documenting the qualifications and training of staff.
The findings include:
On November 2, 2011 at approximately 9:00 AM, the Department licensing representatives requested the Staffing Requirements Facility Summary Report. The facility did not present the completed Staffing Requirements Facility Summary Report until November 2, 2011 at approximately 2:15 PM.
The findings were confirmed by the project director on November 2, 2011.
This was still out of compliance at the time of the follow-up conducted on September 12, 2012.
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Plan of Correction
Project Director and Program Director will ensure that the staffing requirement Facility Summary Report will be completed correctly and have available for DOH staff at the next scheduled site visit. |
Observations
Based on the review of client records, the facility failed to document psychosocial evaluations that included a composite picture of the individual in relationship to the collected historical information in six out of six records.
The findings include:
Psychosocial evaluations in six client records were reviewed on September 9, 2012, specifically in records # 1, 2, 3, 4, 5 and 6. The facility did not document a psychosocial evaluation to include a composite picture of the individual in relation to the collected historical information in client records # 1, 2, 3, 4, 5 and 6.
Client # 1 was admitted on 2/22/12. The psychosocial evaluation in client # 1 ' s record dated 3/20/12 did not include the client ' s assets and strengths, support systems, coping mechanisms, and negative factors.
Client # 2 was admitted on 4/19/12. The psychosocial evaluation in client # 2 ' s record dated 5/3/12 did not include the client ' s assets and strengths, support systems, coping mechanisms, and negative factors.
Client # 3 was admitted on 2/13/12. The psychosocial evaluation in client # 3 ' s record dated 3/1/12 did not include the support systems and negative factors.
Client # 4 was admitted on 2/9/12. The psychosocial evaluation in client # 4 ' s record dated 2/15/12 did not include the client ' s assets and strengths, support systems, coping mechanisms, and negative factors.
Client # 5 was admitted on 2/15/12. The psychosocial evaluation in client # 5 ' s record dated 3/15/12 did not include the client ' s assets and strengths, support systems, coping mechanisms, and negative factors.
Client # 6 was admitted on 3/22/12. The psychosocial evaluation in client # 6 ' s record dated 4/11/12 did not include the client ' s assets and strengths, coping mechanisms, and negative factors.
The findings were confirmed by the clinical supervisor on September 9, 2012.
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Plan of Correction
Effective August 2012 the DBH Practice Guidelines regarding assessing and evaluating client needs was presented to clinical staff. Effective immediately all clinical staff will be updated in their training to document a psychosocial evaluation to include a composite picture,problems/needs, assets/strengths,supportsystems, coping mechanisms, negativefactors, attitude toward treatment and the counselor's conclusions/impressions. This will be presented by the clinical supervisor during regular weekly training sessions. Psychosocial Evaluations will be reviewed with clinicians during regular clinical superision ongoing with the clinical supervisor. In addition, Program Director will review psyochsocials monthly as part of monthly chart reviews. Further review will be conducted by the corporate Performance Quality Improvement Staff as part of ongoing monthly chart audits to assure quality service delivery to all consumers. |