INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 1 through 2, 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 August 25, 2006.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
The project has 13 FTE's and is required to have one full time clinical supervisor and 25 additional hour of clinical supervision. The project had one full time clinical supervisor and a lead counselor providing 10 hours of clinical supervision. The project was lacking 15 hours of clinical supervision.
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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. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
The letter of agreement with Brandywine Hospital did not state 24 hour psychiatric coverage.
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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) 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:
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Observations
The comprehensive treatment plans were not individualized due to the client's type and frequency of services being standardized in eleven of eleven (#1 through 11) client records reviewed. The services should be based on each client's individual needs.
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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 of all previously stated goals in six of eleven records reviewed, # 4, 5, 7, 8, 10 and 14.
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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. |