INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on July 31, 2007 through August 1, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on August 23, 2007.
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Plan of Correction
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document complete personal histories. Specifically, the legal history did not include the dates and outcomes of crimes committed in three of six client records reviewed, #3, 4 and 8. Employment histories did not include a history of the client's past employment in four of five client records reviewed, #2, 3, 5 and 6. Sexual histories were not documented in two of eight client records reviewed, #2 and 5.
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Plan of Correction
1865: Intake and admission documentation: In a weekly staff meeting, Director and Clinical Supervisor will review all subheadings of the psychosocial evaluation. Special attention will be paid to the content of these subheadings, in particular the personal history sections pertaining to legal history to include dates and outcomes of crimes committed, sexual histories and employment histories. Files will also be checked during Clinical Supervision sessions for compliance in these areas on a monthly basis. |
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
Based on a review of client records, the facility failed to document an aftercare plan in one of five client records reviewed, #7. The facility failed to identify goals with time frames on the aftercare plan in three of five client records reviewed, #10, 12 and 14.
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Plan of Correction
1907: Aftercare plans: During a weekly staff meeting, Director and Clinical Supervisor will review with all staff the proper content and documentation of Aftercare Plans. This content must include specific goals with time frames. Director and Clinical Supervisor will revise the current Aftercare Plan document in a list format with a space indicated for time-frames at the end of each goal. Compliance will be reviewed monthly with Clinical Supervisor |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in four of eight client records reviewed, #7, 9, 11 and 14.
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Plan of Correction
1911:Follow-up documentation: In a weekly staff meeting, Director and Clinical Supervisor will review with all staff the procedure for documentation of Follow-up information in all client files. The Director and Clinical Supervisor will change the current policy to reflect follow-up to occur within 90 days of case closing instead of the current 30 days. Follow-up can consist of phone calls, follow-up survey sent to client or follow-up face-to-face visits. The method and whether or not the client responded will be documented on a final casenote in the client file within that 90 day period. These changes will be reflected in a revision of the current policy in our Policy and Procedure Manual. Director will review closed files on a quarterly basis to monitor continued compliance of follow-up and documentation in the appropriate time frames. |