INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 20, 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 November 16, 2006.
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Plan of Correction
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709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Reference results were missing in four of ten records reviewed, #2, 9, 10 and 11.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.23 (2) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
The carpet in group rooms and other high traffic areas were stained and discolored.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Several ceiling lights in the back hallway were not operable and need to be replaced.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Medical histories were missing in two of nine records reviewed, #6 and 8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Parent/guardian signature lines were included on the consent to treatment forms. Parental consent for disclosure of information is not mandated by state law and cannot be required.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 contained historical information rather than the counselor's assessment of the client in nine of nine records reviewed, #1, 2, 3, 4, 5, 6, 7, 8 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 services provided were not documented on treatment plans in six of nine client records reviewed, #2, 3, 5, 6, 7 and 8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
The comprehensive treatment plan did not contain support services based on client needs in nine of nine client records, #1, 2, 3, 4, 5, 6, 7, 8 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Treatment plan updates did not include a review of progress on previously stated goals in five of nine client records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Progress notes did not evaluate or assess the client's progress during treatment in five of nine records reviewed, #2, 4, 6, 7 and 8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
An aftercare plan was missing in one of nine client records reviewed, #8. Aftercare plans did not include goals with realistic time frames, support services, the contact person and re-entry process in three of nine records reviewed, #6, 8 and 9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |