Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, and/or attitude toward treatment.
The findings include:
The facility's policy titled: "Biopsychosocial Assessment," states:
"Self Help Movement will have the client's counselor complete a biopsychosocial assessment within 72 hours of admit date. The Director of Treatment Services or Assistant Director of Treatment Services will sign off on all biopsychosocial assessments ....The integrated summary is an assessment of the bio-psychosocial and is due within 72 hours of client's admission."
On February 2, 2012, five client records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, and/or attitude toward treatment in four of five records reviewed, specifically, client records # 1, 3, 4, and 5.
Client # 1 was admitted December 16, 2011. The psychosocial evaluation was completed December 19, 2011; however, the psychosocial evaluation did not include an evaluation of the client's negative factors and attitude toward treatment.
Client # 3 was admitted December 6, 2011. The psychosocial evaluation was completed December 9, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Client # 4 was admitted December 19, 2011. The psychosocial evaluation was completed December 21, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Client # 5 was admitted December 27, 2011. The psychosocial evaluation was completed December 27, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
The findings were confirmed during an ongoing dialogue with the Director of Administration on February 2, 2012 from approximately 2:45 P.M. to 3:15 P.M.
This is a repeat citation. The facility was cited on August 24, 2011 for noncompliance with this standard.
|
Plan of Correction
Director of Treatment, Quality Improvement Director and Compliance Officer provided training on 2/9/12, regarding the assessment of the client's assets/strengths, support systems, coping mechanisms and attitude towards treatment on the integrated summary; Self Help's assessment document of the psychosocial evaluation. Quality Improvement Director and Compliance Officer will facilitate future staff trainings regarding this assessment to ensure implementation and compliance. |