Observations
Based on a review of client records, the facility failed to document complete psychosocial evaluations in six of six client records.
The findings include:
Six client records were reviewed on February 13, 2009. Psychosocial evaluations were required in six client records. The psychosocial evaluation was missing an evaluation of the client's strengths in client records #1, 2, 3, 4, 5 and 6. The psychosocial evaluation was missing an evaluation of the client's potential or available support systems in client records #1, 2, 3 and 6. The psychosocial evaluation was missing an evaluation of the client's preferred coping mechanisms in client records #1, 4, 5 and 6. The psychosocial evaluation was missing an evaluation of negative factors that might affect treatment in client records #1, 4, 5 and 6. The psychosocial evaluation was missing an evaluation of the client's attitude toward treatment in client records #5 and 6.
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Plan of Correction
The Director of Outpatient Services will facilitate a training session with all pertinent staff on 3/17/09. This training will educate staff on the importance of completing the psychosocial evaluation from the clinician's perspective, with emphasis on covering all the recommended points. The clinician will be able to gather the needed information from the patient's self-assessment and form an evaluation from their own perspective. Random chart reviews will be performed to monitor ongoing completeness of psychosocial evaluations. Any identified deficiencies will be addressed through supervision and additional training as necessary. |