Observations
Two client records were reviewed on June 16, 2017. The facility failed to document a psychosocial evaluation in two of two records reviewed.
Client #1 completed an intake on June 2, 2017. A service plan was developed with the client within 48 hours; however, there was no documented psychosocial evaluation in the record as of the date of the inspection.
Client #2 completed an intake on May 31, 2017. A service plan was developed with the client within 48 hours; however, there was no documented psychosocial evaluation in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
An all staff in service training will be held on July 7, 2017 to address clinical staff on treatment management procedures specific to documenting a completed psychosocial evaluation in all client charts. Client charts # 1 & 2 will have completed evaluations as of 7-14-17. Division Director will follow up with a chart audit to ensure compliance by 8-1-17. The on-site Clinical Supervisor will be responsible for monthly review of all evaluation documentation to ensure completion. |