Observations
Based on the review of client records, the facility failed to complete a psychosocial evaluation in two of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a psychosocial evaluation were reviewed on 1/21/2015 during the renewal inspection. The facility's policy states that psychosocial evaluations are to be completed by the third treatment session. The facility failed to complete a psychosocial evaluation by the third treatment session in client records # 1 and 7.
Client # 1 was admitted to treatment on 3/19/2014. The client's third treatment session was on 4/2/2014. A psychosocial evaluation was not completed for client # 1.
Client # 7 was admitted to treatment on 2/17/2014. The client's third treatment session was on 3/3/2014. The psychosocial evaluation documented in the client's record was not signed and dated by the counselor that completed the document.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following licensure visit on January 21, 2015 clinical supervisor created written summary of site visit feedback and distributed to counselors for their review. Clinical supervisor also discussed directly with counselors need to complete psychosocial evaluation by third session, including counselor signature and date completed.
Counselors were directed by clinical supervisor to review all their active client files and assure psychosocial evaluation was completed with counselor signature and date.
Further discussion of this deficiency will be addressed with counselors at their February 16 treatment meeting. Beginning February 2, 2015 with all newly admitted clients counselors will complete psychosocial evaluation by third session. Clinical supervisor will verify this has been completed for each client at initial client treatment plan review. Facility will be in full compliance with standard by February 28, 2015.
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