Observations
Based on a review of client records and the facility's policy and procedures manual, the facility failed to document a psychosocial evaluation in accordance with the facility's policy.
The findings include:
In reference to biopsychosocial evaluations, the facility's policy states:
The Biopsychosocial Evaluation shall be documented within five days of admission.
On October 17 and 18, 2011 ten inpatient client records requiring documentation biopsychosocial evaluations were reviewed. Ten out of ten inpatient client records reviewed did not include a dated biopsychosocial evaluation of the client, specifically records # 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20.
Client # 11 was admitted on September 6, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within the required five days.
Client # 12 was admitted on September 19, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within the required five days.
Client # 13 was admitted on September 26, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within the required five days.
Client # 14 was admitted on August 30, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within the required five days.
Client # 15 was admitted on August 30, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within the required five days.
Client # 16 was admitted on June 13, 2011 and discharged on July 29, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within the required five days.
Client # 17 was admitted on June 2, 2011 and discharged on July 15, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within the required five days.
Client # 18 was admitted on July 12, 2011 and discharged on July 25, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within the required five days.
Client # 19 was admitted on July 9, 2011 and discharged on July 18, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within the required five days.
Client # 20 was admitted on May 24, 2011 and discharged on July 13, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within the required five days.
The facility director confirmed the findings.
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Plan of Correction
The facility director will modify the signature page to include a signature line and date for the counselor completing the biopsychosocial evaluation. The counselors will also type in the date and their initials at the end of the Clinical Conclusions, Impressions, and Recommendations section of the biopsychsocials in the eletronic records. This will be monitored by the Clinical Supervisors from both units through open and closed chart monitors. These changes will occur no later than 11/21/11. |