INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16-18, 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 May 25, 2007.
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Plan of Correction
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709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. 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 personal history in one of three client records reviewed was not complete. Client record #2 lacked a complete family history, sexual history and recreational history.
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Plan of Correction
The Clinical Director will hold an in-service with all clinical staff to specifically address the issue of personal histories. Scheduled for May 31, 2007 |
709.81(b)(4) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Consent to treatment forms for two of three client records reviewed were not dated by the client, #1 and 3.
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Plan of Correction
The Clinical Director will address the need for client signatures and dates for consent to treatment forms on May 31, 2007 as part of the licensing in-service to be held for all clinical staff. |
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
The psychosocial evaluation for one of three client records reviewed was not completed, #2.
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Plan of Correction
The Clinical Director as part of the licensing in-service will address the psycho-social evaluation and it's importance to treatment planning and treatment in general. May 31,2007. |
709.83(a)(5) 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:
(5) Medication records.
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Observations
One of two client records reviewed failed to document the dosage of medications, #3.
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Plan of Correction
As part of the licensing in-service the Clinical Director will address the need to have clients document their medication doses and entering it into the client record. May 31,2007 |
709.22(c)(3) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(3) Criteria for continued membership.
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Observations
The governing body lacked a written policy outlining criteria for continued membership.
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Plan of Correction
The Executive Director shall present to the Board of Directors a plan to re-introduce criteria for continued membership at the next Board Meeting - June 20, 2007. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Aftercare plans in three of three client records reviewed, #7, 8 and 9, lacked goals with measurable action steps and time frames.
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Plan of Correction
The Clinical Director will include After Care Planning and the need for goals with measureable action steps during the licensing in-service scheduled for May 31, 2007. |