INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 3, 2006 to October 5, 2006 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 November 2, 2006.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
The performance evaluations for staff did have a segment that did assess their training needs. However, this method was not consistent with the agency policy which states that training needs assessments are to be completed in December through the use of an assessment and feedback survey form. The agency needs to follow the written policy.
Evidence of this assessment could include questionnaires completed by all staff with data compiled, or a narrative summarizing group discussion of needs.
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Plan of Correction
The program supervisor will instruct all staff to complete a "Training Needs" form in order to better identify the overall training needs of the staff. This information will be used to develop the annual program training plan. This will be conducted each December. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
The annual evaluation of the overall training plan for the 2005 training year was not completed.
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Plan of Correction
The Program Director will meet with the Program Supervisor to establish an annual training plan based on the feedback provided by staff via their completion of the "Training Needs" form. This will occur in December prior to the beginning of the next training year. A copy of the overall training plan will be kept with the Policy and Procedure manual. |
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
One of eight staff, staff number 4, did not have the required HIV/AIDS or the TB/STD training.
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Plan of Correction
The Program Director will send a memo to the staff member that did not have their HIV/AIDS or TB/STD training to schedule this as soon as possible. A follow-up meeting with this staff member regarding the scheduling of training will be held in one month to see that it was scheduled or completed. |
705.4 (1) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(1) Maintain space for both individual and group counseling sessions.
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Observations
A family session was provided in the client's bedroom at the time of this licensing visit. Counseling areas may not include bedrooms, dining rooms, kitchens, etc. However, a living room or lounge may be used for group activities during non-visitation time periods.
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Plan of Correction
The Program Director will send out a memo to all clinical staff notifying them where and where not to counsel clients. This will be completed within the next week. |
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 nurse/counselor's office was moved behind the partitions in the basement. As was the case at the 2005 licensing inspection, the partitions continue to be inoperable and cannot be closed. Privacy is not afforded to the client should there be anyone else in the basement during a counseling session.
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Plan of Correction
The Program Supervior, and Space Planning Committee have been actively looking at the cost of construction to address this problem as well as relocation of the program. This importance of this issue will be presented to the committee at their next scheduled meeting emphasizing the need for a solution.
In addition to the above action, clinincal staff will be insrtucted to only have one client in the basement area at a time to ensure client confidentiality. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The water tested at 140 degrees.
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Plan of Correction
The Clinical Supervisor will contact Building Maintenance to recalibrate the temperature on the water heater. Done |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
The quarterly inspection covering the months of May, June, and July was missing.
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Plan of Correction
The Quality Manager will contact the the consultant to provide us with the dates she is scheduled for her quarterly inspection of our medication storage area and medication records. The inspection schedule will be placed in the medication storage room so that the clinical supervisor will know when inspecions are to occur. The clinical supervisor will also obtain a copy of the inspection results from the Quality Manager to be kept on site in the medication storage room. |
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
In 3 out of 4 client records reviewed, client numbers 1, 2, and 3, the treatment plans did not have a defined frequency for when individual counseling would be provided. Frequency would vary per treatment objective by stating within 3 days, within 5 days, etc. Treatment groups were also missing from the treatment plan for client number 1.
The frequency of treatment services need to be defined. Examples - group counseling twice a week, family therapy every three weeks, individual counseling once a week, etc.
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Plan of Correction
The Clinical Supervisor will meet with the counselors to go over the importance of accurately completing the Client Treatment Plan pointing out that this is a roadmap of the activites and events that the client will be participating in while in treatment. Emphasis will be placed on the need to identify how often a client intervention, meeting, activity or event will occur during a given time frame. Staff will also be reminded to identify those activities that all clients participate in on a daily basis, ie; treatment or educational groups, AA meetings. This will be completed immediately.
The clinical supervisor will review treament plans over the next month to see that they are being accurately completed. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
The record of services in 3 out of 4 client records reviewed, client number 3, 4, and 5, did not consistently reflect the treatment services provided. These records had progress notes for both individual and group counseling that were not included in the record of services.
Treatment services need to be provided and prescribed in the treatment plan and documented both on the record of services and progress notes.
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Plan of Correction
The clinical supervisor will meet with the staff to remind them that every time they meet with a client, the activity must be entered on the Record of Service form. Also, if a service is provided, it needs to be reflected in the treatment plan or documented in the treatment plan update.
The clinical suprvisor will review charts in one month to see that staff are complying with the above action plan. |