Observations
Based on the review of the annual report, the facility failed to document that the annual report which was made available to the public, included a financial statement of income and expenses.
Findings:
The annual report for the fiscal year ending June 30, 2008 did not document the income and expenses of the program. The annual report documented a pie chart with percentages as to how the money was used. There was no documentation in the annual report that specified an amount of the income and program expenses.
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Plan of Correction
Renewal Treatment Inc. (RTI) will document the income and expenses of the program. RTI will use dollar amounts on the pie charts in the annual report to show income and expenses for each subsequent fiscal year. The Director of Finance will provide the financial information (dollar amounts) to be used for the pie charts documenting income and expenses during completion of the annual report. The CEO and Director of Program Compliance will ensure that this information is included in the annual report prior to its approval and distribution. This will take place during the completion of the annual report for fiscal year ending June 30, 2009. The facility will have the the annual report completed for fiscal year 2008-2009 in November 2009. |
Observations
Based on a review of client records, the facility failed to document psychosocial evaluations that contained clinical assessments of the client's problems/needs, support systems, coping mechanisms and overall conclusions and impressions in ten of eleven records.
Findings:
Thirteen client records were reviewed on February 17-18, 2009. Eleven client records were required to have a psychosocial evaluation. The facility did not document a psychosocial evaluation that included a clinical assessment of the client in records # 1, 2, 3, 4, 6, 7, 8, 9, 10 and 11.
The facility did not document the clients' problems and needs in client records # 1, 2, 3, 4, 6, 7, 8, 9, 10 and 11. The documentation included statements that were not specific to the client and did not include a clinical assessment of the individual clients' problems/needs.
The facility did not document and assess the clients' support system in client records # 2, 4, 7, 9, 10 and 11. The clients' support systems were client reported in records # 1 and 8.
The facility did not document an assessmnet ofthe clients' coping mechanisms in client records # 1, 2, 3, 4, 6, 7, 8, 9, 10 and 11.
The facility did not document a clinical assessment of the counselors' conclusions and impressions in records # 1, 4 and 11. The information was historical and did not include a clinical assessment. In records # 2, 3, 6, 9 and 10 the assessment did not include clinical conclusions and impressions of the client.
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Plan of Correction
The Project Director and Clinical Supervisor will provide training to the counseling staff on the proper completion of psychosocial evaluations. The training will cover how to document clinical assessments of client's problems/needs, support systems, coping mechanisms and overall conclusion. The Project Director and Clinical Supervisors are requiring the counseling staff to complete practice psychosocial evaluations for the purpose of skill evaluation. Additional training will be provided to treatment staff based on their assessed skill level. A narrative description and outline of the psychosocial evalation will be included in each client's file to aid the counseling staff in the completion of all required areas of documentation when completing the evaluations. The documentation of psychosocial evaluation shall be reviewed by the Clinical Supervisors during monthly chart reviews, this review shall ensure the proper documention of all required areas. RTI will be in full compliance by March 13, 2009. |