Observations
Based on a review of policies and procedures and staff interviews, the facility failed to document a written procedure that requires the development of a psychosocial evaluation based on the collected historical information of the client.
The findings include:
The facility's policy and procedure manual was reviewed on August 22, 2011. Per regulation, the governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to: written procedures for the management of treatment/rehabilitation services for clients.
The facility utilizes a file check-in list, documented as D & A form 22. Per the facility's written procedure and D & A form 22, the counselor is required to complete the psychosocial evaluation by the client's second counseling session. The counselor then is required to complete the intake paperwork, which includes the medical, drug/alcohol and personal histories, by the fifth counseling session. Per regulation, the psychosocial evaluation should provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. The facility procedure requires the counselor to complete the psychosocial evaluation prior to actually collecting the historical information. This is inconsistent with the regulation; which requires the psychosocial evaluation to be based on the collected historical information. The facility failed to document a written procedure that requires the development of a psychosocial evaluation based on the collected historical information of the client.
The project and facility directors were interviewed throughout the licensing inspection. The project and facility directors both confirmed the findings. The project director reported this procedure will be revised.
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Plan of Correction
The facility director has updated our current policy that all intake, psycho/socials will be completed by the following timeline of sessions:
Policy has been changed to reflect that counselors will complete the preliminary treatment plan by the first session, intake and psychosocial by the fifth session of opening.
All staff were trained on new policy by the facility direction during their weekly supervision the week of September 6, 2011. The facility director will monitor client records on a monthly basis to ensure staff are documenting this information according the new policy |