Observations
Based upon a review of client records during the licensing inspection on February 15, 2008, the facility failed to provide a complete psychosocial evaluation in four of five client records reviewed, specifically client records #2, 3, 4 & 5. The clinician did not provide an assessment of the client's assets and strengths in client record #3. The clinician did not provide an assessment of the client's potential support systems in client records #2, 3, 4 & 5.
The clinician did not provide an assessment of the clients assets and strengths in client record #3. The clinician did not provide an assessment of the client's coping mechanisms in client records #4 & 5.
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Plan of Correction
Facility psychosocial evaluation forms have been modified to delineate sections for completion from the clinician's perspective regarding client's assets and strengths, potential support systems, and client coping mechanisms, thus ensuring that clinical impressions will be documented rather than client-stated perspectives only.
Staff were re-educated on March 14, 2008 regarding compliance with standards and use of the new forms. The facility director will perform monthly audits in the form of random chart reviews to monitor completeness of psychosocial evaluations. Any identified deficiencies will be addressed through supervision and additional training as necessary.
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