Observations
Based on a review of client records the facility failed to document psychosocial evaluations that included a clinical assessment of the client in eleven of twelve client records as required by regulation.
The findings include:
Twelve client records were reviewed on January 26, 2010. Twelve client records required the completion of psychosocial evaluations, per regulation. Eleven client records did not include a clinical assessment of the client. The facility failed to document a psychosocial evaluation that included a clinical assessment in client records # 1,2,3,4,5,6,7, 8, 9, 10, and 11.
Client # 1's psychosocial evaluation did not include a clinical assessment of the client's assets and strengths, support systems, and negative factors.
Client #'s 2,3,4,5,6, and 7's psychosocial evaluations did not include a clinical assessment of the client's assets and strengths, support systems, coping mechanisms, and negative factors.
Client # 8's psychosocial evaluation did not include a clinical assessment of the client's assets and strengths, support systems, and coping mechanisms.
Client #'s 9 and 10's psychosocial evaluations did not include a clinical assessment of the client's support systems and coping mechanisms.
Client # 11's psychosocial evaluation did not include a clinical assessment of the client's support systems, coping mechanisms, and negative factors.
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Plan of Correction
The Director of OP Services will facilitate a training on 2/26/10 with pertinent clinical staff on psycho-social interviewing and documentation. This training will educate staff on the importance of completing the psychosocial evaluation from the clinician's perspective, with emphasis on covering all the recommended points in each composite picture, as the records do not sufficiently demonstrate their clinical assessment of the client.
Random chart reviews will be performed to monitor ongoing completeness of psychosocial evaluations. Any identified deficiencies will be addressed through supervision and additional training as necessary.
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