Observations
Based on a review of client records, a review of the facilities policy and procedures manual, and a conversation with the clinical supervisor, the facility failed to develop psychosocial evaluations according to policy.The findings include:The facilities policy titled " Comprehensive Biopsychosocial Evaluation" states:Within fifteen (15) work days complete Part I of the Comprehensive Biopsychosocial.The Comprehensive Biopsychosocial Evaluation is a complete gathering of ecological information through client interview, discussion with family members and/or caretakers, review of past and present clinical records and most recent physical examination, and contact with collaborating agencies that leads to a Biopsychosocial formulation, diagnoses, and treatment plan. The purpose of the CBE is to evaluate clinically an individual's need for behavioral healthcare and to assist in determining what type of care is needed.The formulation interweaves the biological, psychological and social factors contributing to the client's difficulties with those that indicate potential success in a treatment setting. The comprehensive formulation leads to accurate diagnosis and to appropriate treatment planning. On August 4, 2011 five client records requiring documentation of psychosocial evaluations were reviewed.The facility failed to document a psychosocial evaluation that included a diagnosis that clinically evaluated the individual's need for behavioral healthcare in four out of five records reviewed, specifically, client records # 2, 3, 4, and 5.In addition, the psychosocial evaluation was completed late in two out or five records reviewed.Client # 2 was admitted to the program on 4/25/11 and discharged on 7/21/11.A psychosocial evaluation was due to be completed by 5/16/11; however the psychosocial evaluation was not complete until 6/21/11.In addition, the psychosocial evaluation failed to clinically evaluate the individual's need for behavioral healthcare Client # 3 was admitted to the program on 3/21/11 and discharged on 7/15/11.A psychosocial evaluation was due to be completed by 4/11/11; however the psychosocial evaluation was not complete until 4/13/11.In addition, the psychosocial evaluation failed to clinically evaluate the individual's need for behavioral healthcare Client # 4 was re-admitted to the program on 1/20/11 and discharged on 4/2/11.The facility documented the psychosocial evaluation on 1/20/11; however, the evaluation failed to include a clinical assessment of the client's problems, needs, asset, strengths, and support systems.Client # 5, an active client at the time of inspection, was admitted to the program on 5/19/11.A psychosocial evaluation was due to be completed by 6/9/11; however the psychosocial evaluation was not complete until 6/10/11.In addition, the psychosocial evaluation failed to include a clinical assessment of the client's problems, needs, assets, and strengths.The clinical supervisor reviewed the chart and did not dispute the findings.
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Plan of Correction
Standard in Noncompliance
709.91(b)(6) LICENSURE Intake and Admission
In an effort to comply with regulation 709.91(b)(6) the written findings from August 4, 2011 were discussed with all Clinical Staff during staff meeting. At which time the Clinical Coordinator reviewed the agency's policy on developing a psychosocial evaluation and documentation which should include a diagnosis that clinically evaluates the individual need for behavioral healthcare. The Clinical Coordinator also reviewed the agency's policy on completing the psychosocial evaluation in a timely manner. Random audit of the counselor's caseload will be conducted by the Clinical Coordinators to ensure that standard 709.91(b)(6) is be followed. Counselors found non-compliant of this regulation will receive additional support from the Clinical Coordinator during weekly supervision sessions. In addition, the Quality Assurance Department will audit newly admitted clients daily to ensure full compliance.
Correction Time: Completed
Monitoring is on-going
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