Observations
Based on a review of client records and clinical documentation, the facility failed to document an evaluative psychosocial assessment in ten of ten records reviewed.The findings include:Ten client records were reviewed for an evaluative psychosocial assessment on April 2 - 3, 2013. The facility failed to document an evaluative psychosocial assessment in ten of ten records reviewed, client record # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10. Client # 1 was admitted to the program on 11/16/12. The psychosocial evaluation was documented on 12/14/12. However, the facility failed document a psychosocial evaluation which included an assessment of the client's attitude toward treatment, assets/strengths, and support systems. Additionally, the psychosocial evaluation did not include the counselor's conclusions/impressions of the client.Client # 2 was admitted to the program on 8/27/12. The psychosocial evaluation was documented on 9/18/12. However, the facility failed to document a psychosocial evaluation which included an assessment of the client's attitude toward treatment, assets/strengths, and support systems. Client # 3 was admitted to the program on 12/7/12. The psychosocial evaluation was documented on 12/25/12. However, the facility failed to document a psychosocial evaluation which included an assessment of the client's attitude toward treatment, assets/strengths, and support systems. Client # 4 was admitted to the program on 1/23/13. The psychosocial evaluation was documented on 2/23/13. However, the facility failed to document a psychosocial evaluation which included an assessment of the client's attitude toward treatment, assets/strengths, support systems, and coping mechanisms. Additionally, the psychosocial evaluation did not include the counselor's conclusions/impressions of the client.Client # 5 was admitted to the program on 12/10/12. The psychosocial evaluation was documented on 1/11/13. However, the facility failed to document a psychosocial evaluation which included an assessment of the client's attitude toward treatment and assets/strengths.Client # 6 was admitted to the program on 12/26/12. The psychosocial evaluation was documented on 1/17/13. However, the facility failed to document a psychosocial evaluation which included an assessment of the client's attitude toward treatment, assets/strengths, support systems, and coping mechanisms.Client # 7 was admitted to the program on 1/20/13. The psychosocial evaluation was documented on 2/25/13. However, the facility failed to document a psychosocial evaluation which included an assessment of the client's attitude toward treatment, assets/strengths, support systems, and coping mechanisms. Additionally, the psychosocial evaluation did not include the counselor's conclusions/impressions of the client.Client # 8 was admitted to the program on 9/28/12. The psychosocial evaluation was documented on 10/3/12. However, the facility failed to document a psychosocial evaluation which included an assessment of the client's assets/strengths and support systems.Client # 9 was admitted to the program on 6/25/12. The psychosocial evaluation was documented on 7/24/12. However, the facility failed to document a psychosocial evaluation which included an assessment of the client's attitude toward treatment, assets/strengths, and support systems.Client # 10 was admitted to the program on 5/11/12. The psychosocial evaluation was documented on 6/8/12. However, the facility failed to document a psychosocial evaluation which included an assessment of the client's attitude toward treatment and assets/strengths.The clinical supervisor did not dispute the findings.
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Plan of Correction
The clinical supervisor will hold in-service trainings to continue to address the need for comprehensive, individualized and strength based assessments. The trainings will be concentrated on staff development, and the need to provide clear descriptions or assessment of the necessity of treatment. The comprehensive assessment process should reflect engagement with the client, while building a relaxed rapport with him or her and address any immediate problems or crises that may present. It should individualize treatment based on factors known to have an effect on service outcomes (spirituality, culture, gender, strengths, experience of trauma, co-occurring conditions). It should promote hope and enhance resilience, while encouraging client participation in the community. It should assess strengths, abilities, preferences, needs, and challenges that impact the PIR's hopes and dreams (goals). Two mandatory half day trainings will be conducted no later than July 30, 2013. The clinical supervisor will also follow up with each clinical staff during their face-to-face supervisions in order to prevent reoccurrence. The Program Director will also assert that the clinical supervisor conducts the trainings and that its being addressed in supervisions through weekly meetings held with management staff.
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