INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5 through 6, 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 June 28, 2006.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
The overall training plan was not completed as per policy.
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Plan of Correction
Project Director misunderstood the standard, believing compiling all individual training plans would constitute the Agency Annual Training Plan. This error has been corrected and an Agency Annual Training Plan is completed effective 6/7/06. Completed by Project Director 6/7/06. Reviewed with staff 6/7/06. |
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
The personal medical history was missing any prior hospitalizations in records #1, 2, 3, 4, 5 and 6.
The review of client's symptoms was missing in records #1, 2, 3, 4, 5 and 6.
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Plan of Correction
Our medical history form was not comprehensive enough to inclide prior hospitalizations and review of symptoms. Project Director has developed a new Medical History Form to include these (2) deficient areas on 6/7/06. Staff were trained in proper completion of form 6/7/06. New for will appear in all new client records effective 6/8/06. All clinical records will be reviewed by Project Director in 45 days to assure compliance.
All corrections and additions were made to current active records where ever possible. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The lengths and patterns of use was incomplete in records # 3, 4, 5 and 6.
Prior treatment information was missing dates and outcomes in records # 1, 4 and 5.
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Plan of Correction
We had been using a BDAP Demographics / Psycho Social form that was neither comprehensive nor user friendly. In addition, in some cases, staff were not fully completing sections of the form we were using. Effective 6/9/06 the Project Director has developed a new Psycho-Social data collection form that will be used in all clinical records. Project Director will conduct an inservice with all staff on 6/14/06 to teach/train proper completion of form with emphasis on all areas identified as deficient. (1863,1865) All clinical records will be reviewed by Project Director in 45 days to assure compliance.
All additions and correction were made to active client records where ever possible. |
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
The family history was lacking the family of origin in records #1, 4, 5 and 6.
The employment history was missing dates of employment and reasons for leaving in records #1, 4, 5 and 6.
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Plan of Correction
We had been using a BDAP Demographics / Psycho Social form that was neither comprehensive nor user friendly. In addition, in some cases, staff were not fully completing sections of the form we were using. Effective 6/9/06 the Project Director has developed a new Psycho-Social data collection form that will be used in all clinical records. Project Director will conduct an inservice with all staff on 6/14/06 to teach/train proper completion of form with emphasis on all areas identified as deficient. (1863,1865) All clinical records will be reviewed by Project Director in 45 days to assure compliance.
All additions and correction were made to active client records where ever possible. |
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
There were two incomplete evaluations being utilized by the facility. There needs to be one complete psychosocial evaluation form. Client's assets/strengths were missing in records #1 and 2. Support systems were not evaluated in records #1, 2 and 3.
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Plan of Correction
The Project Director has consolidated both evaluations into one evaluation with identified areas for assets/strengths and support systems. Project Director will conduct an inservice with all staff on 6/14/06 to train staff in proper completion of the new form. New form will appear in all new clinical records by 6/15/06. All clinical records will be reviewed by Project Director in 45 days to assure compliance. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
The record of services did not include the duration of service for individual sessions in records #1, 2, 3, 4, 5 and 6.
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Plan of Correction
All staff were incorrectly entering the actual time of session on Record of Service Form. Project Director has trained/supervised all staff to enter the length of session (ie. 50 minutes, 1 1/2 hours, ect.) on Record of Service Form rather than the time. Completed 6/7/06 |