INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 2 - 4, 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 3, 2007.
|
Plan of Correction
|
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
|
Observations
Monthly meetings between the Executive Director and the Clinical Supervisor failed to document duties and performance in the position of Clinical Supervisor from the date of hire in that position to the date of the inspection, which represents a 3 months period.
|
Plan of Correction
The Clinical Supervisor will meet with the Executive Director on a monthly basis and document these meetings beginning from April through October 2007 (6 months). The Clinical Supervisor's duties and performance in the position will be well documented in these supervisory notes. |
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.
|
Observations
The facility lacked documentation that employee #5 had the 6 hour training of the mandatory HIV/AIDS training.
|
Plan of Correction
Employee #5 will complete the mandatory 6-hour HIV/AIDS training on May 16, 2007. All newly hired counselors/counselor assistants will complete this mandatory training within 1 year of employment. Clinical Supervisor will ensure that this training is done in the recommended time period for all new hires |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
The facility failed to ensure compliance with the client to counselor caseload size of 35:1. The FTE counselor caseload was 118:1.
|
Plan of Correction
Per recommendation of licensing, in order to ensure compliance with client to counselor caseload size, the facility will increase number of individual sessions, decrease number of group sessions, and document all aspects of case management and crisis management being provided to participating clients. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Fire extinguisher training was not provided to employee # 2 within seven days of employment.
|
Plan of Correction
All future hires will receive appropriate training on fire extinguisher usage. In addition to this individual training for new hires, a yearly training will be provided for all employees. Clinical Supervisor will maintain education material for fire extinguisher training and ensure that the training is done within 7 days of hire. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Emergency training was not provided to employee # 2 within seven days of employment.
|
Plan of Correction
All futre hires will receive appropriate emergency training within 7 days of being hired. The Clinical Supervisor will ensure that this training is done within that amount of time. |
709.22(e) 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:
|
Observations
The facility's annual report for the 2005 -2006 year was not completed.
|
Plan of Correction
The annual report will be available 5/15/07. Delay was due to audit completion date. The deadline for th ecompletion of the single audit is March 31st of each year. Executive Director will encourage earlier submission of audit in order for the annual report to be completed earlier and available for the review during inspection. |
709.22(e)(1) 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:
(1) Activities and accomplishments of the preceding year.
|
Observations
The facility failed to complete an annual report and failed to make such a report available to the public. The annual report documents activities and accomplishments for the previous fiscal year. The facility had no annual report for the fiscal year of 2005-2006.
|
Plan of Correction
The annual report will be available 5/15/07. Delay was due to audit completion date. Executive Director will encourage earlier submission of audit in order for the annual report to be completed earlier and available for the review during inspection. |
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.
|
Observations
The facility lacked an annual report documenting the financial statement of income and expenses for the fiscal year of 2005-2006.
|
Plan of Correction
The annual report will be available 5/15/07. Delay was due to audit completion date. Executive Director will encourage earlier submission of audit in order for the annual report to be completed earlier and available for the review during inspection. |
709.22(e)(3) 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:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
|
Observations
There facility lacked an annual report documenting a statement disclosing the names of officers, directors and any principal shareholders.
|
Plan of Correction
The annual report will be available 5/15/07. Delay was due to audit completion date. Executive Director will encourage earlier submission of audit in order for the annual report to be completed earlier and available for the review during inspection. |
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:
|
Observations
Treatment plans were not individualized due to the lack of individual counseling sessions. Facility documentation indicated that the facility was only conducting group sessions at the time of the survey.
|
Plan of Correction
Per recommendation of licensing, in order to ensure compliance with appropriate treatment plan development, the following changes will be made:
- Treatment plans will reflect all individualized and group treatment provided.
- There will be an increase in individual counseling sessions provided.
- Individual counseling sessions will be documented on the client log, progress notes and treatment plan.
Clinical Supervisor will take responsiblity for training all staff on appropriate protocol and will audit 1-2 charts a month to ensure treatment plans are being done correctly |
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.
|
Observations
Treatment plan updates for two of four clients receiving medical assistance lacked the physician's signature. This was evidenced in client records # 1 & 7.
|
Plan of Correction
All 60 day Treatment Plan Updates will be reviewed by a physician and signed for all MA clients. |
709.93(a)(2) 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:
(2) Medication records.
|
Observations
Medication records in three of four client records reviewed failed to indicate whether the client was on any medication and the dosage and frequency of use. This was evidenced in client records # 2, 3 & 4.
|
Plan of Correction
Per recommendation of licensing, appropriate documentation regarding medication records will be recorded in the Bio-Psych-Social paperwork. If no medications are given, this will be documented in the appropriate section.
Clinical Supervisor will audit 1-2 charts a month, randomly, to ensure changes are being made and that the medication records are filled out appropriately. All staff will be trained in the importance of properly documenting the medication record. |