Observations
Based on a review of client records, the facility failed to complete psychosocial evaluations in three of eight client records.
Findings:
Eight client records were reviewed on March 15, 2010. Psychosocial evaluations were required in four client records. The counselors did not evaluate the client's when it came to the client's problems/needs, assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment of the client in client record #6. Also, in client records #3 and 4 did not have documentation of psychosocial evaluation. Per the facility policy and procedure it states that psychosocial evaluations are to be completed within 30 days of the clients admit date. Client #3 was admitted on November 11, 2009 and as of to date client record did not have documentation of psychosocial evaluation. Client #4 was admitted on November 15, 2009 and as of to date client record did not have documentation of psychosocial evaluation.
|
Plan of Correction
By April 30, 2010, the Clinical Supervisors will conduct an in-service to all Counselors on the policy and procedure for completing the psycho social evaluation. The in-service will address the appropriate completion of the psycho social evaluation and timeliness. The Clinical Supervisors will be responsible for reviewing the psycho social evaluation of a new admission during weekly supervision to ensure the completion of the psycho social evaluation and that the deficiency does not reoccur. |