Observations
Based on a review of client records, and a review of the facility's policy and procedures manual, the facility failed to document a psychosocial evaluation in one of five records reviewed.
The findings include:
On October 19, 2012, five client records requiring documentation of a psychosocial evaluation were reviewed. The facility failed to document a psychosocial evaluation in one of five records reviewed, specifically, client record # 2.
The facility policy states " It is the policy of the PATH Licensed Outpatient Drug and Alcohol Program to complete a comprehensive evaluative summary of the Bio-Psycho-Social History on every individual within 15 days from the date of intake."
Client # 2 was admitted to the program on 8/13/12. An evaluative summary was due within 15 days from the date of intake. However, the client did not return to treatment until 9/10/12, and was also serviced on 10/1/12 and 10/8/12. The facility failed to document a psychosocial evaluation at the time of review on 10/19/12; or within 15 days per policy.
The Facility Director and the counselor confirmed the findings.
|
Plan of Correction
The clinical staff person will ensure compliance with this standard for all new and future clients by completing the psychosocial evaluation according to agency policy of 15 days from the date of intake. Ongoing compliance with this standard will be ensured through training, ongoing supervision and quarterly quality reviews by the facility director. |