INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 14, 2006 to March 16 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 April 11, 2006.
Over capacity
709.14 Restriction on License (a)(5) Authorized capacity
Facility has a census of 186 for the Outpatient activity which exceeds the authorized maximum capacity of 180.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Feedback is not being consistently documented for external trainings for all employees. Internal trainings appear to be well documented.
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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 |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The overall ratio exceeds the 35/1 standard at 41/1. Also, employee number 3, 5, 6, and 7. exceeded the individual caseload ratio as follows: #3 = 44/1; #5 = 43/1; #6 = 52/1; #7 = 42/1.
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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 |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Client record A addressed the client's problems/needs, assets/strengths, support systems, and coping mechanisms from the client's perspective. The evaluations also need to include the counselors perspective based on information collected. Client records B and C, with the exception of the composite picture, had identical information word for word in the evaluation. Evaluations need to identify each individual's relationships, conditions and causes leading to the client's current situation.
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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 |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 treatment plans for client records A and B did not identify group treatment and the frequency at which it is to occur. The treatment plans for client records B and C did not include the type and frequency of treatment services.
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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 |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Client records B and C had treatment plan updates that had the exact information word for word including typographical errors. Treatment plan updates need to assess each client's individual progress in relationship to the stated goals of the comprehensive treatment plan.
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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 |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Client record A had a consent from another agency to "obtain" information from Serento Gardens. Serento Gardens released information based on this consent to obtain information and did not secure the client's consent to release information to this agency. Client record O, G, and E did not have consents to release information to the third party payors and/or insurance companies.
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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 |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Client record D indicated that the client was involuntarily discharged. Progress notes indicate the client was informed verbally, however, regulation requires that the client be informed in witting and a copy of this notice should be maintained in the client's record.
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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 |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Client record D indicated that the client was involuntarily discharged. Progress notes indicate the client was informed verbally of his/her right to request reconsideration of a decision terminating treatment. However, this right should be included in the termination notice itself and/or in a client rights statement disclosed to the client during intake/orientation.
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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)(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
Client records E, F, G, H, and J did not consistently identify the type and frequency of treatment services.
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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 |
709.93(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
Follow-up contacts were not documented as per agency policy for client records M, N, and R.
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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 |