Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within 30 days of first session, per facility policy, in four of seven records reviewed. Client #2 was admitted to the outpatient activity on June 25, 2025 and was discharged on September 17, 2025. A psychosocial evaluation was not documented in client record. Client #3 was admitted to the outpatient activity on July 2, 2025 and was discharged on December 16, 2025. A psychosocial evaluation was not documented in client record.Client #4 was admitted to the outpatient activity on May 30, 2025 and was discharged on September 19, 2025. A psychosocial evaluation was not documented in client record.Client #7 was admitted to the outpatient activity on July 30, 2025 and was active during licensing process. A psychosocial evaluation was not documented in client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Biopsychosocial Assessments were conducted for all clients referenced in the citation. However, the required summary section was documented within a different area of the client's electronic health record rather than within the Biopsychosocial Assessment itself.
During Meadowlark Counseling Services' review of policies and procedures in the summer of 2025, the agency identified this workflow issue and requested that our electronic health record system, DENmaar, modify the Biopsychosocial Assessment template to include a designated summary section within the assessment form.
As a result of this modification, all Biopsychosocial Assessments completed on or after January 15, 2026 (update version 8.21.17) include the required summary within the assessment document. This change ensures the summary is contained directly within the Biopsychosocial Assessment and addresses the documentation deficiency cited.
The Clinical Supervisor will continue to review documentation through routine chart audits to ensure ongoing compliance with assessment documentation requirements. This plan of correction is effective March 20, 2026 and overseen by the Clinical Supervisor.
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