Observations
Based on a review of client record documentation and an interview with the facility director, the facility failed to document personal histories which addressed family relationships, education, military, sexual and employment histories in 4 of 4 client records.
The findings included:
Four client records were reviewed during the onsite inspection. Four of four records reviewed failed to include documentation of a complete personal history. The facility director was interviewed regarding the format used for the collection of personal histories. The collection of histories has been integrated into the electronic Smart 2 K system developed and used by this project for client record documentation. The format of the histories does not adhere to the regulation requirements in terms of prompting the writer to give details on each of the components specified, consequently, details were omitted from each of the histories reviewed.
Facility policy, as stated on pp.123-126 of the hard copy of the onsite policy and procedure manual stated that assessments were to include an evaluation of: Drug and Alcohol abuse history and treatment history, health history, psychiatric history, treatment acceptance /resistance, 12 step participation, employment, social, legal, housing, educational, economic, gambling history and risks, cultural, spiritual and nutritional histories.
Client record # 1 - this client was admitted on 5/10/11 and last treated on 5/10/11. The personal history was reviewed on 5/20/11. The following components were missing in this record: an employment history, a family history which detailed family interrelationships, an educational history, a sexual history and any indication as to whether or not the client had ever served in the military. Gambling history and risks, cultural, spiritual and nutritional dimensions were not addressed as per facility policy.
Client record # 2 - this client was admitted on 3/24/11 and last treated on 5/11/11. The personal history was reviewed on 5/20/11. The following components were missing in this record: an employment history, a family history which detailed family interrelationships, an educational history, a sexual history and any indication as to whether or not the client had ever served in the military. Gambling history and risks, cultural, spiritual and nutritional dimensions were not addressed as per facility policy.
Client record # 3 - this client was admitted on 3/16/11 and last treated on 5/13/11. The personal history was reviewed on 5/20/11. The following components were missing in this record: an employment history, a family history which detailed family interrelationships, an educational history, a sexual history and any indication as to whether or not the client had ever served in the military. Gambling history and risks, cultural, spiritual and nutritional dimensions were not addressed as per facility policy.
Client record # 4 - this client was admitted on 3/8/11 and last treated on 5/10/11. The personal history was reviewed on 5/20/11. The following components were missing in this record: an employment history, a family history which detailed family interrelationships, an educational history, a sexual history and any indication as to whether or not the client had ever served in the military. Gambling history and risks, cultural, spiritual and nutritional dimensions were not addressed as per facility policy.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
The clinical Supervisor and
the Regional Clinical Director,
Charles Jones will hold a training on
June 21, 2011, so that all
associates have an
understanding that each Intake Psychosocial will have
complete personal history,
which will include family
relationships, education, military, sexual and employment, documented
for all new patients entering into treatment. The Clinical
Supervisor and Lead Counselor
will read over each Intake
Psychosocial to ensure there is a completed personal history for
each patient prior to saving the
document complete. The
Program Director will do
sporadic checks to monitor
compliance.
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Observations
Based on a review of client record documentation and an interview with the facility director, during the unannounced licensing inspection, the facility failed to document psychosocial evaluations which addressed client needs, strengths, support systems, coping mechanisms, negative factors impacting treatment, attitude toward treatment and/or counselor conclusions/impressions in four of four client records.
The findings included:
At the time of the onsite inspection four client records were reviewed. Four of four records reviewed failed to address the psychosocial evaluation requirements in detail. The facility director was interviewed regarding the format used for the collection of psychosocial evaluations. The psychosocial evaluation has been integrated into the electronic Smart 2 K system developed and used by this project for client record documentation. The system has integrated the psychosocial evaluation and the history into one document in the Smart 2 K system. The format of the evaluations does not adhere to the regulation requirements in terms of prompting the writer to give details on each of the components specified, consequently, details were omitted from each of the evaluations reviewed.
Facility policy on page 125 of the onsite manual regarding the interpretive summary uses generic language which does not address the detail required by the regulation.
Client record # 1 - this client was admitted on 5/10/11 and last treated on 5/10/11. The psychosocial evaluation was reviewed on 5/20/11. The evaluation failed to include documentation of a composite picture of the client, client needs, coping mechanisms and counselor conclusions/impressions.
Client record # 2 - this client was admitted on 3/24/11 and last treated on 5/11/11. The psychosocial evaluation was reviewed on 5/20/11. The evaluation failed to include documentation of a composite picture of the client, client needs, coping mechanisms and counselor conclusions/impressions.
Client record # 3 - this client was admitted on 3/16/11 and last treated on 5/13/11. The psychosocial evaluation was reviewed on 5/20/11. The evaluation failed to include documentation of a composite picture of the client, client needs, coping mechanisms and counselor conclusions/impressions.
Client record # 4 - this client was admitted on 3/8/11 and last treated on 5/10/11. The psychosocial evaluation was reviewed on 5/20/11. The evaluation failed to include documentation of client needs, coping mechanisms and support systems.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
The Clinical Supervisor and
the Regional Clinical Director,
Charles Jones will hold a
training on June 21, 2011,
so that all associates document
psychosocial evaluations
which addressed client needs, strengths, support systems,
coping mechanisms, negative factors impacting treatment, attitude
toward treatment and/or
counselor conclusions. The
Clinical Supervisor and Lead
Counselor will read over
each intake psychosocial to
ensure there is a completed
psychosocial evaluation for
each patient prior to saving
the document complete. The
Program Director will do
sporadic checks to monitor compliance.
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