INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 2 and 3, 2007 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 May 2, 2007.
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Plan of Correction
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709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
The facility failed to complete a performance report summarizing the progress towards meeting goals and objectives.
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Plan of Correction
The progress towards meeting goals and objectives was not clearly articulated in the annual report. The intent is that progress is displayed through completion of each goal by interjecting a complete date. However this does not include a clear summary.
The Facility Director will ensure meeting goals and objectives a clear summary is included in the annual report indicating progress towards each goal and if there is no or partial progress towards a certain goal the reason will be indicated as well as the plan to move towards completion of the goal. This will be completed by 5-31-07.
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709.26(b)(1) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(1) Confidential maintenance of personnel records.
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Observations
The policy did not identify all individuals who have access to records. The policy did not include a procedure for releasing information to outside agencies.
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Plan of Correction
This was not outlined in the policy. The Facility Director has corrected this policy to include identification of all individuals who have access to records and the procedure for releasing information to outside agencies |
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 six of thirteen client records reviewed, # 1, 2, 4, 7, 9 and 13.
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Plan of Correction
The clinical supervisors have not always reviewed each intervention.
The clinical supervisors will now review each intervention from the comprehensive against the update to ensure review of progress towards each goal is completed. Staff training has been scheduled for 5-16- 07. This will start 5-21-07.
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709.94(d) LICENSURE Project management services
709.94. Project management services.
(d) The project shall develop a written client aftercare policy.
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Observations
The policy did not include a time frame for the completion of an aftercare plan. The policy did not include a description of the areas addressed in the plan.
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Plan of Correction
The Facility Director has modified the policy to include time frame of completion of aftercare plan as well as the areas address on the aftercare plan. |