INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6, 2006 to November 8, 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 December 13, 2006.
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Plan of Correction
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations lacked sufficient evaluative content in 4 of 4 client records reviewed, record numbers 1, 2, 3, and 4. The client problem list and support systems were identical in each evaluation.
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Plan of Correction
Explaination: Clinicians were vague on the psycosocial content. Timeframe: On December 5 2006 the facility will be in full compliance with this regualtion. Course of Action: We have already sent a new psycosocial form to be approved by licensure. Upon approval,it will be explained to all clinicians at an in-service held on 12/5/06, where the importance of individualization will be defined and the identification of different problem areas and support systems will be identified. Teamleader will monitor that the psycosocials are being completed properly at bi-weekly reviews. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The treatment plan updates failed to include the client's progress for each goal in 4 of 4 client records reviewed, record numbers 1, 2, 3, and 4.
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Plan of Correction
Explaination: Clinicians were vague on the progress clients made on their treatment plans. Timeframe: On December 5 2006 the facility will be in full compliance with this regualtion. Course of Action: We have already sent a new comprehensive treatment plan review form to be approved by licensure. Upon approval, it will be explained to all clinicians at an in-service held on 12/5/06, where the importance of updating the treatment plans, reviewing the treatment plans with residents, and identifing progress the client has made on goals will be addressed. The Teamleader will monitor that the Comprehensive Treatment Plan reviews are being completed properly in bi-weekly reviews. |