Observations
Based on a review of partial hospitalization activity client records, the facility failed to provide an individualized psychosocial evaluation in three of four records.
The findings include:
Fourteen client records were reviewed on March 19, 2013. Four of the nineteen records were reviewed for the partial hospitalization activity. Three of the four records included psychosocial evaluations which were similar in content and were verbatim between the three documents.
Client record #1 - patient was admitted to partial hospitalization on 1-16-2013 and discharged on 2-26-2013. The psychosocial evaluation was completed on 1-30-2013. Client records #1, 3 and 4 included psychosocial evaluations which were similar in content and were verbatim.
Client record #3 - patient was admitted to partial hospitalization on 3-7-2013. The psychosocial evaluation was documented. Client records #1, 3 and 4 included psychosocial evaluations which were similar in content and were verbatim.
Client record #4 - patient was admitted to partial hospitalization on 2-28-2013. The psychosocial evaluation was completed on 3-13-2013. Client record #1, 3 and 4 included psychosocial evaluations which were similar in content and were verbatim.
The findings were reviewed with the director and were not disputed.
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Plan of Correction
We are aware that psychosocial evaluations need to be individualized. We had a new staff member who had just started writing evaluations and who was following an example that we had provided a little too closely. This staff member, and all other clinical staff members, have been reminded the proper way to write up an individualized and comprehensive bio psychosocial evaluations. Clinical supervisors will routinely review evaluations to monitor compliance. In addition, the facility director will pull random samples on a monthly basis for additional review. This change has already been instituted. |