Observations
Based on the review of client records the facility failed to document a psychosocial evaluation in two of three client records.
The findings include:
Five client records were reviewed on December 30, 2009. Of those five client records, psychosocial evaluations were reviewable in three records. The facility did not document a psychosocial evaluation in client records # 1 and 2.
Interviews with the facility director and the clinical supervisor were conducted on December 30, 2009. The facility director and clinical supervisor stated their policy is to document a psychosocial evaluation within 30 days from the date of admission for each client.
The admission date for Client # 1 was 11/24/09, but the psychosocial evaluation was not documented at the time of review on December 30, 2009.
The admission date for Client # 2 was 10/6/09, but the psychosocial evaluation was not documented at the time of review on December 30, 2009.
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Plan of Correction
The Therapist failed to complete and record the psychosocial evaluation in a timely fashion for Client #1 and Client# 2. The Therapist was addressed in supervision and the work was completed. The Clinical Supervisor will review the therapist's records weekly for three months to insure compliance. To insure on-going compliance the Clinical Supervisor and Director will conduct monthly scheduled reviews The first review was conducted on 1/6/2010 and full compliance will be April 6, 2010.
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