Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client in three of eight outpatient client records.
The findings include:
Twelve client records were reviewed on September 10, 2012. Eight client records pertained to the outpatient activity and required documentation of a psychosocial evaluation. The facility failed to document a psychosocial evaluation that included a clinical assessment of the client in client records # 5, 8 and 11.
Client # 5 was admitted into treatment on July 26, 2012. The psychosocial evaluation was completed on May 10, 2012. The psychosocial evaluation included client reported historical information and was not a clinical assessment of the client.
Client # 8 was admitted into treatment on July 28, 2012. The psychosocial evaluation was completed on July 11, 2012. The psychosocial evaluation included client reported historical information and was not a clinical assessment of the client.
Client # 11 was admitted into treatment on June 27, 2012. The psychosocial evaluation was completed on June 20, 2012. The psychosocial evaluation included client reported historical information and was not a clinical assessment of the client.
The facility director was interviewed on September 10, 2012 and confirmed the findings.
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Plan of Correction
Clinical Supervisor will review findings and provide examples to clinicians on accurately writing Psychosocial Evaluations including appropriate clinical assessment and impressions.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly clinical staffings and chart reviews. |