Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to document a psychosocial assessment according to the facility's policies and procedures.
The findings include:
The facility's policy states, the psychosocial evaluation is to be completed within 30 days of the patient's admittance into the program.
On January 18, 2012 five client records were reviewed for psychosocial evaluations. Three out of five client records lacked documentation of a clinical assessment, specifically client records # 1, 3, and 6.
Client # 1 was admitted on October 27, 2011. The psychosocial evaluation was due to be completed by November 28, 2011. As of the date of inspection, there was no psychosocial evaluation completed for client # 1.
Client # 3 was admitted on April 28, 2011. The psychosocial evaluation was due to be completed by May 31, 2011. As of the date of inspection, there was no documentation of a psychosocial evaluation for client # 3.
Client # 6 was admitted on June 30, 2011. The psychosocial evaluation was due to be completed by August 1, 2011. As of the date of inspection, there was no documentation of a psychosocial evaluation for client # 6.
On January 18, 2012 the findings were confirmed with the facility director and clinician.
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Plan of Correction
It is the policy of the Division of Substance Abuse programs that histories and psychosocial summaries are completed within 30 days of admission. Those charts that were found to be non-compliant were for clients who had been discharged and then re-admitted within a short period of time. The counselor responsible for these charts was not aware that she needed to update the psychosocial summary with each admission. The Program Director, who is also the Coordinator of Treatment for the Division of Substance Abuse, has met with the program staff responsible on 2/13/12 to review findings and to clarify procedures. New and re-admitted charts will: 1-have a blank psychosocial inserted at intake, to ensure an older version is not reused, and 2-will be reviewed by the Program Director for a period of four months to ensure satisfactory remediation of the deficiency.
Clients #1 and #3 are both chronically non-compliant with treatment (inconistent attendance) and have not attended treatment since before the site visit in January. Therefore the program has not been able to update their biopsychosocial summaries. The plan is for both of these clients to be discharged by the end of the month if not attending treatment. If we are able to retain these patients, their biopsychosocial summaries will be updated by the end of the month.
client Chart #6 was discharged 12/30/11, before the site visit took place. |