INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11 - 12, 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 July 13, 2007.
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Plan of Correction
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709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
The governing body failed to select the project director as outlined in the organizational bylaws, Article 9 section 9.6. which states the project director is appointed to the position of Chief Executive Officer and board president by the governing body. Documentation on the staffing requirements facility summary report completed on June 8, 2007 failed to include the project director as required in the bylaws.
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Plan of Correction
Governing body misunderstood the selection process for Project Director according to our Bylaws. The Board met on 6/25/07 to discuss deficiency and rectified this by appointing the Chief Executive Officer as the Executive Project) Director. On 6/25/07, the Board voted and approved a new Project Director to comply with our Bylaws. |
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 facility failed to include documentation of the frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plans in nine of nine client records reviewed.
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Plan of Correction
Our treatment plan failed to include specific type and frequency on a consistent basis. Facility Director developed a new Treatment plan form on 6/15/2007 to include a section specific to type of service and frequency for each individualized treatment plan. All staff was trained in proper completion of new form 6/20/07 and new form will be utilized in any new comprehensive treatment plan developed after this date. Facility Director will ensure compliance by utilizing our Quality Assurance Procedures. |