INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 21 through 23, 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 June 18, 2007.
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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 forms were not completed for all training in three of three personnel records reviewed, #1, 2 and 14.
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Plan of Correction
The Staff Development policy and procedure has been updated as follows:
(form will be mailed to Department Office).
Evaluations of all staff development/inservices activities must be completed by all participants. Internal training evaluations must be completed and submitted to the Staffing Coordinator within five (5) business days of the on-site training. Evaluations of external or off-site trainings and seminars must be completed by the participant and submitted to the Human Resources Director within 10 days of attending the training.
Evaluations forms will be distributed by the Human Resources Director to all participants at the beginning of all on-site trainings and will be distributed to when notified they will attend a training off site.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Individual training plans failed to document employee input in the development of the training plan in three of nine records reviewed, #2, 6 and 14.
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Plan of Correction
The distribution of Training Needs Assessment will be included with all probationary evaluations and annual evaluations to ensure receipt of employee input.
Project Director will mandate that mgmt staff encourage all employees to provide input to the development of staff's Individual Training Plans; this input will then be documented. Should an employee decline this offer, this too will be documented.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to provide documentation of TB/STD training in one of seven records reviewed, #6.
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Plan of Correction
Human Resource Coordinator to schedule these required trainings, continuing to assure Department approved curriculum and trainers, throughout 2007. Schedule to be posted by June 15, 2007. Memo-randums will be distributed to all staff to announce trainings and department managers will be notified when their staff are due for attendance. A spread-sheet will be utilized by HR to track attendance by all staff. The individual identified as deficient will be sent to the first available training. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The group counseling areas did not allow for visual privacy.
Group room #3 had windows and a glass door to the exterior which did not allow for visual privacy.
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Plan of Correction
Window and door coverings (operational blinds) were installed on May 25, 2007 to the windows of Group Room #3, to ensure privacy during counseling sessions and group therapy. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Temperature logs indicated that the freezer registered at 3 degrees Fahrenheit eight of twenty-three days during the month of May, specifically May 10, 11, 12, 13, 16, 17, 18 and 22.
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Plan of Correction
All dietary staff have been trained on reading and recording proper freezer temperatures as well as how to properly complete the temperature log sheets. Training of all staff completed on June 2, 2007. All dietary staff have been tested and have shown competence in this area.
Staff have also been instructed to report any variations of temperatures to Plant Operations Manager.
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709.53(a)(9) LICENSURE Aftercare plans
709.53. 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:
(9) Aftercare plan, if applicable.
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Observations
Aftercare plans either lacked documented goals with time frames or the time frames and/or goals were not realistic in three of three records reviewed, #4, 5 and 6.
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Plan of Correction
The aftercare form has been revised to allow for the staff to assist the client in formulating both detailed and realistic goals that are time specified. All staff assisting in the aftercare process have been trained on proper completion of the new form. The Clinical Director trained the Aftercare Coordinator and Social Workers on 6/9/07, the Clinical Director will also monitor this process to ensure compliance. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 information was documented late in two of three records reviewed, #5 and 6.
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Plan of Correction
The Aftercare Coordinator and all Social Workers have been trained on the aftercare follow-up procedure including timeframe regulations. An EXCEL spreadsheet has been developed to streamline this procedure. The Clinical Director will monitor this process on a weekly basis to ensure 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
The treatment plan update did not provide an accurate assessment of the clients's progress in relationship to the stated goals in one of one record reviewed, #11. The update indicated that goals and objectives were met, however, progress notes and the case consultation indicated that the client was not complying with requirements of the treatment plan and that the goals and objectives were not met.
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Plan of Correction
The facility director will oversee that all clinical staff are educated in a staff meeting to be held 7/6/07, on completing a thorough treatment plan update which accurately summarizes and reflects the client's progress in the past 60 days and is consistent with case consults and progress notes of the client record. Ongoing monitoring will be conducted by the Director of outpatient and individual instruction will be provided as needed for staff who are not in compliance with set standards |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Progress notes failed to identify action steps, the counselor's plan, and/or client assignments or tasks relevant to treatment in three of three records reviewed, #11, 12 and 13.
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Plan of Correction
The facility director will oversee that all clinical staff are educated in a staff meeting to thoroughly complete the data and assessment portions of the progress notes. Ongoing monitoring will be conducted by the Director of Outpatient and Risk Manager to ensure that progress notes are completed in compliance with set standards. OP staff training was held June 4, 2007 focusing on proper documentation of progress notes, including all elements of the DAP format. In addition, the new counselor responsible for these particular records will be provided weekly supervision to strengthen her skills and understanding of required documentation and intervention techniques. |
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 not conducted as required to discuss problematic clients who were not responding to treatment strategies in three of three records reviewed, #11, 12 and 13. The facility conducted case consultations shortly before the clients were to be discharged.
The disposition stated that the clients successfully completed treatment which contradicted the case consultation summary and the progress notes.
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Plan of Correction
When a client is failing to make progress relative to treatment plan objectives and treatment interventions, the primary therapist will be expected to discuss the case at a weekly peer-to-peer review session. Alternative treatment strategies will be discussed and documented for inclusion on a written case consult form. The practice of recording all case consultations which are occurring in peer-to-peer discussions will be implemented and monitored by the Facility Director. Training occurred on 6/12/07 with all staff. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Aftercare plans were not individualized nor did they include goals and objectives identified by the client with time frames in three of three client records reviewed, #11, 12 and 13 . The form was a template with pre-defined goals.
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Plan of Correction
The facility director trained clinical staff on the required components of the Aftercare plan and the need to include future goals with time frames for completion of goals and support services in the plan, this training occurred on 6/12/07. Proper form protocol will be reinforced and the Director of Outpatient will assure compliance with standards through medical records audits that will occur monthly. |