Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation which included proposed support systems in four of seventeen client records and counselor conclusions/impressions in seven of seventeen client records.
The findings include:
Twenty-one client records were reviewed on April 6-9, 2009. Psychosocial evaluations including proposed support systems and counselor conclusions/impressions were required in seventeen client records.
The facility did not document proposed support services in client records # 5, 9, 11 and 14.
The facility did not document counselor conclusions/impressions in client records # 3, 5, 6, 7, 11, 12 and 15.
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Plan of Correction
Staff 1:1 supervision, staff clinical team meetings, staff internal and external trainings as well as staff development articles will address the need on psycho-social assessments to be more diagnostic and evaluative and less factual with regard to counselor conclusions/impressions. The need to identify and document proposed support systems more specifically will also be an emphasis in supervision and trainings. Random monthly chart audits by the Clinical Director and Executive Director will be conducted as part of the supervision plan. |