INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 30, 2006 through November 3, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on December 4, 2006.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
The assessment of staff training needs was not completed as per the facility's policy. The policy stated that the assessment will be completed in June of every year, however, the staff assessment was not completed until December 2005.
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Plan of Correction
Staff training needs will be assessed in June in compliance with policy effective June, 2007. Implemented by Staff Growth and Development Chairperson.
Director of counseling will monitor the Staff Growth and Development Chairperson to ensure compliance with staff growth and development assessament of staff training needs as stated in policy. Supervision will occur in June, 2007 through annual performance appraisal. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Two of the facility's drivers (#21 and 24) did not have CPR certification.
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Plan of Correction
The Facility drivers will have CPR certificaiton by November 30, 2006. Responsible person: Director of Admissions.
Compliance with CPR certification will be monitored annually at the time of performance evaluations for the drivers by the Director of Admissions. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The hot water temperature registered at 140 degrees Fahrenheit.
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Plan of Correction
Water temperature is turned down to 120 degrees effective immediately by Maintenance Supervisor.
This will be monitored by monthly faciilty walk throughs by QI director, Safety Committee Chairperson and Maintenance Supervisor. Water temperatures will be randomly taken in patient bed rooms and recorded to ensure compliance by the maintenance supervisor. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Showers located in the family residence rooms in the outpatient services building did not have slip resistant surfaces .
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Plan of Correction
Slip strips installed immediately by Maintenance Supervisor.
This will be monitored through monthly facility walk throughs by QI Director, Safety Committee Chairperson and Maintenance Supervisor.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
There were space heaters in two individual counselor offices located in the temporary modular building.
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Plan of Correction
Space heaters removed from facility immediately by Maintenance Supervisor.
Continuing compliance will be monitored through monthly facility walk throughs by the QI Director, Safety Committee Chairperson and Maintenance Supervisor. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The fire drill record did not include the exit route used for fire drills.
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Plan of Correction
Exit routes added to fire drill record by December, 2006 by Maintenance Supervisor. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
The exit routes used were not documented on the fire drill record.
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Plan of Correction
Alternate exits added to fire drill record by January 1, 2007 by Maintenance Supervisor.
Each staff will receive a copy of the alternate exit routes to be used during fire drills by January 1, 2007. Maintaining compliance is the responsiblity of the Maintenance Supervisor. |
709.81(b)(5) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Physical examinations were completed by a physician's assistant, but were not co-signed by the physician. The physical examination was missing in client record #12. The agency policy requires that all clients have a physical examination.
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Plan of Correction
For the partial and outpatient programs, the policy for physical examinations will be changed to reflect the revised licensing standards. The policy will go into effect November 22, 2006.
Outpatient coordinator will ensure compliance with the policy which no longer requires all patients to have a physical examination. This will occur through individual supervision with partial outpatient counselors. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations were missing or contained information that was limited to the client's input regarding client assets/strengths, support systems, coping mechanisms and negative factors that may affect treatment in three of three client records reviewed, #12, 13 and 14.
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Plan of Correction
The training will be conducted for the inpatient, partial and outpatient counseling staff. The training will focus on the areas cited in the psychosocial evaluation:
assets/strengths
support systems
coping mechanisms
negative factors
counselor's conclusions/impressions
To assist counselors, a template will be developed and demonstrated as part of the training. The training will occur by Nov. 16, 2006 and all charts will be monitored for the next 6 months to ensure compliance by all counseling staff.
Counseling coordinators will be responsible for ensuring corrective actions are implemented. This will be accomplished through weekly individual supervision and monitoring with the counseling staff by counseling coordinators. |
709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
Physical examinations were completed by a physician's assistant, but were not co-signed by the physician.
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Plan of Correction
The electronic medical record has been amended to allow a progress note to be entered by the physician once the history and physical examination have been reviewed. This amendment went into use November 18, 2006.
Information technology coordinator amended the electronic medical record and the medical director is responsible for maintaining continued compliance. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluation was missing assets/strengths in one of 19 client records reviewed, #3 and were incomplete in eight of 19 records reviewed, #1, 2, 4, 5, 6, 10, 11 and 19. Support systems were missing or incomplete in eight of 19 client records reviewed, #2, 4, 5, 6, 9, 10, 11 and 19. The client's coping mechanisms were missing in six of 19 client records reviewed, #1, 2, 9, 10, 11 and 19. Negative factors that may inhibit treatment were missing or incomplete in six of 19 client records reviewed, #1, 2, 4, 5, 6 and 10. The psychosocial evaluation was missing counselor conclusions/impressions in one of 19 client records reviewed, #10 and were incomplete in three of 19 client records reviewed, #1, 2 and 4.
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Plan of Correction
A training will be conducted for the inpatient, partial and outpatient counseling staff. The training will focus on the areas cited in the psychosocial evaluation:
assets/strengths
support systems
coping mechanisms
negative factors
counselor's conclusions/impressions
To assist counselors, a template will be developed and demonstrated as part of the training. The training will occur by November 30, 2006 and all charts will be monitored for the next 6 months to ensure compliance by all counseling staff.
Counseling coordinators will be responsible for ensuring corrective actions are implemnted. This will be accomplished through weekly individual supervision and monitoring with the counseling staff by the counseling coordinators. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Physical examinations were completed by a physician's assistant, but were not co-signed by the physician.
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Plan of Correction
The elctronic medical record has been amended to allow a progress note to be entered by the physician once the history and physical examination have been reviewed. This amendment went into use November 18, 2006.
Information technology coordinator amended the electronic medical record and the medical director is responsible for maintaining continued compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluation was missing assets/strengths in one of 19 client records reviewed, #3 and were incomplete in eight of 19 records reviewed, #1, 2, 4, 5, 6, 10, 11 and 19. Support systems were missing or incomplete in eight of 19 client records reviewed, #2, 4, 5, 6, 9, 10, 11 and 19. The client's coping mechanisms were missing in six of 19 client records reviewed, #1, 2, 9, 10, 11, and 19. Negative factors that may inhibit treatment were missing or incomplete in six of 19 client records reviewed, #1, 2, 4, 5, 6 and 10. The psychosocial evaluation was missing counselor conclusions/impressions in one of 19 client records reviewed, #10 and were incomplete in three of 19 client records reviewed, #1, 2 and 4.
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Plan of Correction
A training will be conducted for the inpatient, partial and outpatient counseling staff. The training will focus on the areas cited in the psychosocial evaluation:
assets/strengths
support systems
coping mechanisms
negative factors
counselor's conclusions/impressions
To assist counselors, a template will be developed and demonstrated as part of the training. The training will occur by November 30, 2006 and all charts will be monitored for the next 6 months to ensure compliance by all counseling staff.
Counseling coordinators will be responsible for insuring corrective actions are implemented. This will be accomplished through weekly individual supervision and monitoring with the counseling staff by the counseling coordinators. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
The medical history form did not include family medical history in five of five client records reviewed, # 15, 16, 17, 18 and 19.
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Plan of Correction
The Electronic Medical Record will be modified to include questions that will provide the means to more fully record the significant medical history of family members. The Electronic Medical Record will be modified and the staff will be trained in its use by November 30, 2006.
The electronic medical record was modified by information technology coordinator. The counseling coordinators will monitor completion of the family medical history to ensure complete compliance. This will occur through individual weekly supervision with counselors. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
The physical examination was completed by a physician's assistant and not co-signed by the physician in one of five client records reviewed, #18. A physical examination was missing on one of five records reviewed, #15. The agency policy requires that all clients have a physical.
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Plan of Correction
For the partial and outpatient programs, the policy for physical examinations will be changed to reflect the revised licensing standatds. This policy will go into effect November 22, 2006.
Outpatient coordinator will ensure compliance with the policy which no longer requires all patients to have a physical examination. This will occur through individual supervision with partial and outpatient counselors. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations were missing or contained information that was limited to the client's input for assets/strengths, support systems, and coping mechanisms in five of five records reviewed, #15, 16, 17, 18 and 19.
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Plan of Correction
A training will be conducted for the inpatient, partial and outpatient counseling staff. The training will focus on the areas cited in the psychosocial evaluation:
assets/strengths
support systems
coping mechanisms
negative factors
counselor's conclusions/impressions
To assist counselors, a template will be developed and demonstrated as part of the training. The training will occur by November 30, 2006 and all charts will be monitored for the next 6 months to ensure compliance by all counseling staff.
Counseling coordinators will be resposible for ensuring corrective actions are implemented. This will be accomplished through weekly individual supervision and monitoring with the counseling staff by the counseling coordinators. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The type and frequency of treatment services was not included in the treatment plan in two of five records reviewed, #18 and 19. The frequency of treatment services was not included in the treatment plans in three of five records reviewed, #15, 16 and 17.
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Plan of Correction
The electronic medical record has been modified as of November 20, 2006 to ensure that the type and frequency of services will always be included in the treatment plan.
The electroninc medical record modified by the information technology coordinator. Outpatient program coordinator is responsible for ensuring corrective actions are implemented and is responsible for monitoring continued compliance through individual supervison. |