INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on May 22, 2007 through May 25, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on June 18, 2007.
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Plan of Correction
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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
The facility failed to include a statement of income and expenses within the annual report.
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Plan of Correction
The facility has a Manual for Public Review available at all times. This manual contains several items including our annual audit as well as our annual report. We were under the impression that having the audit available showing our income and expenses complied with the standard. The CEO and Deputy Director will correct this area in December 2007 by including our income and expenses in our agency newsletter (the annual report). This will be maintained on a yearly basis by the CEO and Deputy Director. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to have hot water at or below 120F. The hot water registered at 140F.
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Plan of Correction
Our facility had the temperature of the hot water set at 120F, however during the year it must have fluctuated and reached a temperature of 140F. The Deputy Director will contact our heating contractors and have them adjust the hot water temperature back to 120F. This will be checked on a monthly basis by the maintenance person. This will be done by 6/20/07. |
709.82(a) 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:
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Observations
The facility failed to develop individualized treatment plans based on each client's needs in three of three client records reviewed, #1, 2 and 3.
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Plan of Correction
Although some of the stated problem areas and goals on the clients treatment plans were similar, we felt this was appropriate in that they had the same issues to be addressed in treatment. The Treatment Supervisor and Clinical Consultant recognizes the need for the treatment plans to be more specific with the areas clearly stated; therefore a training will be conducted for all clinical staff on critical thinking relating to individualized treatment plans. The implementation of this training will be monitored on a bi-monthly basis by the Treatment Supervisor and Clinical Consultant by reviewing case files. This Training will take place by July 30, 2007. |
709.82(a)(3) 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:
(3) Proposed type of support service.
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Observations
The facility failed to document proposed type of support services on the individual treatment plan in three of three client records reviewed, #1, 2 and 3.
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Plan of Correction
The support services were listed in the progress notes, however the partial therapist were remiss in not listing them on the individualized treatment plans. A meeting was held with the partial therapists one week following the licensing visit and this issue of support services was clearly explained by the Treatment Supervisor. By June 15, 2007 this area will be corrected. It will be monitored on a bi-monthly basis by the Treatment Supervisor and Clinical Consultant by reviewing clinical charts. |
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
The facility failed to include an assessment of the client's progress in relationship to the previously stated goals in three of three client records reviewed, #1, 2 and 3.
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Plan of Correction
Our facility did not meet the standard because we wrote a narrative summary of the client's progress on the treatment plan review instead of addressing the individual goals that were stated on the treatment plan. By July 30, 2007 a training will held regarding this clinical information ie. clearly stating the progress on each stated goal on the treatment plan reviews. Treatment Supervisor and Clinical Consultant will be in charge of this and will monitor the clinicans through staff meetings and chart reviews on bi-monthly basis. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
The facility failed to present a clear disposition of cases reviewed within the case consultation notes in three of three client records reviewed, #1, 2 and 3.
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Plan of Correction
In the Case Consultation it appears that the disposition was too brief and did not give a clear picture of the client's status in treatment at this time, therefore the standard was not met. By June 30, 2007 Treatment Supervisor and Clinical Consultant will review in the staff meeting how to present a more concise and clear picture of the client in the disposition relative to more information that happened throughout the discussion with the clinical team and the recommendations for future treatment. It will be montiored on a bi-monthly basis through staff meetings and chart review as well as case consultation themselves. |
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 facility failed to develop individualized treatment plans based on client needs in three of seven client records reviewed, #1, 3 and 6.
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Plan of Correction
Although some of the stated problem areas and goals on the clients treatment plans were similar, we felt this was appropriate in that they had the same issues to be addressed in treatment. The Treatment Supervisor and Clinical Consultant recognizes the need for the treatment plans to be more specific with the areas clearly stated; therefore a training will be conducted for all clinical staff on critical thinking relating to individualized treatment plans. The implementation of this training will be monitored on a bi-monthly basis by the Treatment Supervisor and Clinical Consultant by reviewing case files. This Training will take place by July 30, 2007. |
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
The facility failed to include an assessment of the client's progress in relationship to the previously stated goals in six of six client records reviewed, #1, 3, 4, 5, 6 and 7.
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Plan of Correction
Our facility did not meet the standard because we wrote a narrative summary of the client's progress on the treatment plan review instead of addressing the individual goals that were stated on the treatment plan. By July 30, 2007 a training will held regarding this clinical information ie. clearly stating the progress on each stated goal on the treatment plan reviews. Treatment Supervisor and Clinical Consultant will be in charge of this and will monitor the clinicans through staff meetings and chart reviews on bi-monthly basis. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
The facility failed to present a clear disposition of cases reviewed within the case consultation notes in seven of seven client records reviewed, #1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
In the Case Consultation it appears that the disposition was too brief and did not give a clear picture of the client's status in treatment at this time, therefore the standard was not met. By June 30, 2007 Treatment Supervisor and Clinical Consultant will review in the staff meeting how to present a more concise and clear picture of the client in the disposition relative to more information that happened throughout the discussion with the clinical team and the recommendations for future treatment. It will be montiored on a bi-monthly basis through staff meetings and chart review as well as case consultation themselves. |