Observations
Based on a review of eight client records reviewed on September 30, 2008, the facility failed to document complete psychosocial evaluations in eight of eight records where required.
Findings:
Psychosocial evaluations were incomplete, missing the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that my inhibit treatment, the client's attitude towards treatment and the counselors' conclusions/impressions in client records #1, 2, 3, 4, 5, 6, 7 and 8
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Plan of Correction
Following the Drug and Alcohol Program audit staff and contractors were re-educated on October 1, 2008 specific to proper and complete documentation on all forms most specifically the psychosocial evaluation. Simultaneous to this, re-education was provided to staff/contractors on the regulation requirement for documentation and the expected standards 709.91 (b) (6).
All psychosocial evaluations completed since 10/1/08 will be re-evaluated by Program Director/designee for compliance standards by November 1, 2008. Any identified deficiencies will be addressed with specific clinicians in individual supervisions scheduled weekly. Any identified deficiencies will be corrected within the timelines expected for psychosocial evaluation completion.
Effective 11/1/08, weekly random audits will be completed by the Program Director/designee assigned compliance duties to ensure the quality of psychosocial evaluations is maintained.
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