Observations
Client records were reviewed on July 26, 2016. Based on this review, the facility failed to complete a psychosocial evaluation in one of thirteen client records.
Client #13 was admitted on March 16, 2016 and was still an active client at the time of this inspection. A psycholocial evaluation was not documented in the client chart as being completed.
The findings were reviewed with the facility director.
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Plan of Correction
The Facility Director reviewed with the Clinical staff during clinical meeting on 8/5/16 that effective immediately assessments from other providers will not be used in lieu of completing Gaudenzia's Bio-Psychosocial.
The clinical staff will complete the Gaudenzia Bio-Psychosocial during the evaluation.
This will be monitored and reviewed by the Program Director during monthly QI audits. |