Observations
Based on a review of agency policy and procedure, client records, and an interview with the clinical supervisor, the facility failed to document psychosocial evaluations as per agency policy, within 15 days of the date of admission, in three of five client records.
The findings include:
Six partial hospitalization client records were reviewed on June 29 & 30, 2010. Documentation of a psychosocial evaluation was due in five of the client records reviewed. The facility did not document psychosocial evaluations as per the agency policy in client records # 2, 5 and 6. In addition, the comprehensive treatment plan was developed prior to completing the psychosocial evaluation in client records # 2, 5 and 6.
Client # 2 was admitted on October 7, 2009. The psychosocial evaluation was due to be completed by October 22, 2009. The psychosocial evaluation was completed on November 2, 2009. The comprehensive treatment plan was documented on October 23, 2009. The treatment plan is to be based on the findings documented in the psychosocial evaluation.
Client # 5 was admitted on November 24, 2009. The psychosocial evaluation was due to be completed by December 9, 2009. The psychosocial evaluation was completed on December 21, 2009. The comprehensive treatment plan was documented on December 7, 2009. The treatment plan is to be based on the findings documented in the psychosocial evaluation.
Client # 6 was admitted on August 6, 2009. The psychosocial evaluation was due to be completed by August 21, 2009. The psychosocial evaluation was completed on August 24, 2009. The comprehensive treatment plan was documented on August 13, 2009. The treatment plan is to be based on the findings documented in the psychosocial evaluation.
An interview with the clinical supervisor took place on June 30, 2010 at which time it was confirmed that the psychosocial evaluations documented in the aforementioned client records were not documented as per the agency policy.
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Plan of Correction
The Clinical Supervisor will meet immediately with all staff in individual supervision meetings to review the policy and procedures for completing psychosocial evaluations, within 15 days of the date of admission, and the completion of treatment plans. The procedure will also be reviewed at clinical staffings in August and September. It shall be the responsibility of the Clinical Supervisor to ensure remediation and compliance with regard to this policy through weekly chart audits and ongoing supervision. |
Observations
Based on a review of agency policy and procedures, client records and an interview with the clinical supervisor, the facility failed to document treatment plan updates every 30 days as per agency policy and regulation in four of four client records.
The findings include:
Six partial hospitalization client records were reviewed on June 29 & 30, 2010. Four of the clients reviewed were in treatment for a time period which required treatment plan updates. The facility did not document treatment plan updates as per agency policy and regulation in client records # 2, 3, 5 and 6.
Client # 2 was admitted on October 7, 2009. The comprehensive treatment plan was completed on October 23, 2009. Treatment plan updates were due to be completed by November 23, 2009, December 23, 2009, January 23, 2010, February 23, 2010, March 23, 2010, April 23, 2010, May 23, 2010 and June 23, 2010. There were no treatment plan updates documented for the months of November 2009, February 2010, April 2010 and May 2010.
Client # 3 was admitted on April 1, 2010. The comprehensive treatment plan was completed on April 14, 2010. Treatment plan updates were due to be completed by May 14, 2010 and June 14, 2010. There was one treatment plan update completed on May 20, 2010. The clinical supervisor reported that this client was stepped down from partial hospitalization to the intensive outpatient level of care as of June 21, 2010.
Client # 5 was admitted on November 24, 2009 and discharged on April 9, 2010. The comprehensive treatment plan was completed on December 7, 2009. The clinical supervisor reported that this client was stepped down from partial hospitalization to the intensive outpatient level of care as of January 22, 2010. Treatment plan updates were due to be completed on January 7, 2010, January 22, 2010 and March 22, 2010. Two treatment plan updates dated January 7, 2010 and February 8, 2010 were documented. There was no treatment plan update for March 22, 2010.
Client # 6 was admitted on August 6, 2009 and discharged on January 18, 2010. The comprehensive treatment plan was completed on August 13, 2010. The clinical supervisor reported that this client stepped down from partial hospitalization to the intensive outpatient level of care as of October 9, 2009. Treatment plan updates were due to be completed on September 14, 2009, October 9, 2009 and December 9, 2009. Treatment plan updates dated September 14, 2009, October 14, 2009 and November 16, 2009 were documented. There was no treatment plan update for January 16, 2010.
An interview with the clinical supervisor took place on June 30, 2010 at which time the aforementioned dates were confirmed. The clinical supervisor provided the dates that the clients were stepped down to a lower level of care as a treatment plan update or new comprehensive treatment plan was not documented to reflect the change in level of care.
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Plan of Correction
The Clinical Supervisor will meet immediately with all staff in individual supervision meetings to review the policy and procedures for the completion of treatment plans within the required timeframe. The due dates and processes for each, with particular emphasis on treatment planning requirements when individuals change level of care, will be included in these meetings. The procedure will also be reviewed at clinical staffings in August and September. It shall be the responsibility of the Clinical Supervisor to ensure remediation and compliance with regard to this policy through weekly chart audits and ongoing supervision. Further, the Clinical Supervisor will conduct a review of any case changing level of care to assure the standards are being met. |