Observations
Based upon the review of client records, the facility failed to document psychosocial evaluations that were legible or that included an assessment of the client's problems/needs, assets/strengths, potential or available support systems, preferred coping mechanisms, negative factors that might affect treatment, attitude toward treatment and/or counselor conclusions/impressions in five of eleven client records.
The findings include:
Thirteen client records were reviewed on February 15, 2013, with eleven client records requiring documentation of psychosocial evaluations. The facility failed to document psychosocial evaluations that were legible or that included assessments of the client's assets/strengths, potential or available support systems, preferred coping mechanisms, negative factors that might affect treatment, and/or counselor conclusions/impressions in client records # 1, 2, 3, 4 and 11.
Client # 1 was admitted on September 10, 2012, and was still an active client on the date of inspection. The record included a psychosocial evaluation that was dated September 10, 2012. However, the psychosocial evaluation did not include an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors that might affect treatment and the counselor's conclusions/impressions.
Client # 2 was admitted on August 22, 2012, and was still an active client on the date of inspection. The record included a psychosocial evaluation that was dated August 22, 2012. However, the psychosocial evaluation did not include an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors that might affect treatment, attitude toward treatment and the counselor's conclusions/impressions.
Client # 3 was admitted on October 12, 2012, and was discharged on January 29, 2013. The record included a psychosocial evaluation that was dated October 19, 2012. However, the psychosocial evaluation did not include an assessment of the client's assets/strengths, support systems, coping mechanisms and the counselor's conclusions/impressions.
Client # 4 was admitted on July 20, 2012, and was still an active client on the date of inspection. The record included a psychosocial evaluation that was dated July 23, 2012. However, the psychosocial evaluation did not include an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors that might affect treatment and the counselor's conclusions/impressions.
Client # 11 was admitted on May 21, 2012, and was discharged on September 6, 2012. The record included a psychosocial evaluation that was dated May 21, 2012. However, the assessment of the client's problems/needs, assets/strengths, potential or available support systems and the counselor's conclusions/impressions were not legible.
The findings were reviewed with the Facility Director, the Vice President of Quality Improvement and the Director of Quality Improvement during the exit interview.
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Plan of Correction
The Clinical Supervisor will meet with all clinical staff during staff meeting and review the psychosocial evaluation, highlighting how to document assessment of the client's problem/needs, assets/strengths, potential or available support systems, preferred coping mechanisms, negative factors that might affect treatment, attitude toward treatment and/or counselor conclusions/impressions.
This clinic is now utilizing electronic records. The psychosocial evaluation is completed electronically and will no longer be handwritten, eliminating legibility concerns.
After staff are re-educated, the Vice President of Quality Improvement and/or the Director of Quality Improvement will audit a sample of psychosocial evaluations to monitor for improvement and ensure compliance. |