Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included the client's problems/needs, assets/strengths, support systems, coping mechanisms and/or negative factors as they would relate to treatment. In addition, the psychosocial evaluations failed to include the counselor's evaluation of the client.
The findings include:
On October 12, 2011, five client records were reviewed for documentation of a psychosocial evaluation. The facility failed to document an evaluative psychosocial in four of five client records reviewed.
Client # 1 was admitted to the program on 5/24/11.
The psychosocial was documented on 5/24/11. However, the facility failed to document an evaluation of support systems and coping mechanisms. In addition, the psychosocial was not evaluative as the document contained a list and stated "the patient reports."
Client # 2 was admitted to the program on 5/16/11.
The psychosocial was documented on 5/16/11; however, the psychosocial evaluation was not legible at the time of review; thus it could not be determined if the evaluation provided a composite picture of the individual in relation to the collected historical information, the client's underlying problems, problems that cannot be resolved through treatment or that might inhibit treatment, assets, strengths or other factors that contribute to the identified problems, support systems, negative factors, coping mechanisms,conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the clients attitude toward and ability to participate in the treatment process.
Client # 3 was admitted to the program on 6/13/11.
The psychosocial was documented on 6/13/11. However, the facility failed to document an evaluation that included assets/strengths, support systems, and coping mechanisms.
In addition, the psychosocial was not evaluative as the document contained a list and stated "the patient reports."
Client # 4 was admitted to the program on 10/25/10.
The psychosocial was documented on 10/25/10. However, the facility failed to document an evaluation that included a composite picture of the individual in relation to the collected historical information, the client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors. In addition, the psychosocial failed to document conclusions regarding the client's attitude toward and ability to participate in the treatment process. Furthermore, the psychosocial was not evaluative as the document contained a list and stated "the patient reports."
The clinical director did not dispute the findings.
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Plan of Correction
Two Staff meetings will be conducted, one by Clinical Director on 11/8/11 and another by the Director on 11/15/11. The Staff meeting will inform all clinicians who complete Psychosocial evaluations that utilization of "patient reports" is not acceptable. "Patient reports" does not cover the counselor's evaluation. The staff will be given contrasting examples between "Patient reports" and a counselor evaluation in order to identify the difference. Legibility will be stressed and individual counselors will be offered the ability to type the document. The Clinical Director will review all psychosocial evaluations completed in December 2011 for complete evaluation by the counselor and legibility. Results will be shared with the counselors in the January staff meeting. Results that are seen to be Counselor specific will become part of a Performance Management issue for the specific counselor. |