INITIAL COMMENTS
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This report is the 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 the inspection and a plan of correction is due on July 6, 2007.
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Plan of Correction
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to document the frequency of treatment and rehabilitation services on the individual treatment plan in three of four client records reviewed, #1, 3 and 4.
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Plan of Correction
On 6/14/07, the Clinical Supervisor held a staff meeting. During this meeting, treatment plans were discussed. She went over the proper way to document on the plans paying particular attention to documenting the frequency and type of contact for each goal. The Clinical Supervior will be responsible for insuring future compliance in this matter through supervision, chart reviews and review of each treatment plan with the counselor prior to distribution to the client. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
The facility failed to follow their own written policy regarding the time frame for completion of case consultation notes. The facility's written policy noted that case consultations would be completed on the client's sixtieth day of treatment. Case consultations were missing in three of four client records reviewed, #1, 2 and 3.
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Plan of Correction
The policy was changed by the Director of Operations on 6/14/07 to reflect the current procedures the clinical staff is following to document case consultations for each client. Case consultations for 90 day client will be completed after the 60th day of treatment. |