INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11, 2007 through June 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 5, 2007.
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Plan of Correction
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
A space heater was found in the project director's office.
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Plan of Correction
The space heater was removed from the office on 6/18/07, and will not be utilized anywhere on-site. Program Director will continue to monitor on an ongoing basis to ensure space heaters are not used in any other office at any time. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The 2007 project goals and objectives did not include time frames and available resources.
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Plan of Correction
Although some of the goals and objectives indicated the required information, Program Director will review current 2007 plan, and make necessary changes to include time frames and resources, by 7/1/07. All future plans will thoroughly describe time frames and resources for project goals and objectives. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Consent to release information forms did not include the specific information to be released in four of five client records reviewed, #1, 2, 4 and 5.
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Plan of Correction
Program Director reviewed individual charts in which consent to release information were deficient. Director will review forms with staff responsible for correction during individual supervision meetings to occur before 7/1/07. All necessary changes will to release forms will be made by 7/1/05. Program Director will monitor on an ongoing basis for compliance. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
The facility failed to provide documentation that copies of consent forms were offered to the client in three of five client records reviewed, #1, 4 and 5.
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Plan of Correction
Program Director will meet individually with staff responsible for client charts #1,4 and 5 to correct insufficient documentation on consent forms, by 7/1/07. Consent forms will be correctly completed to reflect clients being offered a copy, by 7/1/07. Program Director will instruct staff during team meeting on 6/22/07 for refresher. Program Director will monitor on an ongoing basis. |
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
Psychosocial evaluations did not provide an evaluation of the client's assets/strengths, support systems, coping mechanisms, and negative factors that may inhibit treatment in five of five client records reviewed, # 1, 2, 3, 4 and 5.
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Plan of Correction
This particular finding has previously been addressed administratively prior to this inspection by rearranging the psychosocial evaluation form to provide information on the client's assets/strengths, support systems, coping mechanisms, and negative factors that may inhibit treatment. However,
client records #1,2,3,4 and 5 were completed prior to this change on old forms that are out of circulation. Inspection team was presented with the new, updated form for review during on-site inspection, which presumably met with approval. Program Director will address the importance of only using the updated psychosocial evaluation form during team meeting on 6/22/07. Program Direcotr will monitor on an ongoing basis for compliance and will only accept evaluations completed on the revised form. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Treatment plans did not include measurable criteria in three of five records reviewed, # 1, 2 and 5.
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Plan of Correction
Program Director will review charts #1,2 and 5 with staff responsible for completing treatment plans, by 7/1/07. Staff will be instructed to document measurable criteria of goals and interventions. Program Director will monitor on an ongoing basis for compliance. |
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
Treatment plan updates did not provide an assessment of the client's progress in relationship to previously stated goals in four of five records reviewed, # 1, 2, 3 and 5.
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Plan of Correction
Program Director will meet individually with staff responsible for treatment plans for clients #1,2,3 and 5 to instruct and advise how to adequately reflect client progress in relationship to treatment plan goals, by 7/1/07. Director will address with team at meeting on 6/22/07 to ensure full understanding. Director will adapt Tx Plan form to allow for more space to write in this area by 7/1/07, and will monitor on an ongoing basis for compliance. |
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
Case consultations were missing in two of six client records reviewed, #2 and 3. The facility failed to complete a case consultation within the required time frame in one of five client records reviewed, #5.
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Plan of Correction
Program Director will review charts #2,3 and 5 by 6/22/07. Director will be more conscientious of recording case consultations on a consistent and timely basis in all future situations, and will develop a system for tracking due dates. Effective immediately, all case consultations will be completed as required by this standard. Director will monitor on an ongoing basis for compliance. |