Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in three of seven client records.
Findings:
Twelve client records were reviewed on January 14-15, 2009. Seven were reviewed as outpatient client records. Seven client records were required to have psychosocial evaluations. The facility did not document a psychosocial evaluation of the client based on the client's history and intake information in client records #8, 9 and 12.
In client records # 8, 9 and 12, the information documented in the evaluations was a repeat of demographic information and historical data. The documents did not provide a clinical evaluation of the client.
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Plan of Correction
THE CLINICAL MANAGER MET WITH THE CLINICIANS WHOSE DOCUMENTATION WAS IN QUESTION AND REVIEWED THE DOCUMENTATION MANUAL AND THE PROPER COMPLETION OF THE EVALUATIVE SUMMARY FORM. MANAGER TO REVIEW CHARTS MONTHLY TO ENSURE ACCURATE COMPLETION. REVIEWER SHARED EXAMPLE OF A "GOOD SET OF CLINICAL IMPRESSIONS" AND MANAGER SHARED THIS EXAMPLE WITH THE CLINICIANS. |