INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 16 through 17 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 February 13, 2007.
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Plan of Correction
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
A financial audit was not provided for the last fiscal year.
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Plan of Correction
Audit to be completed within six months of the end of the fiscal year.
The Program Director will monitor compliance.
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709.26(b)(2) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(2) The dissemination of employment information to project staff.
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Observations
The program did not have a policy for this standard.
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Plan of Correction
Holcomb Behavioral Health System's Policy and Procedures will be ammended to state that the dissemination of personnel management issues will be done thru payroll stuffings, internal postings, e mail, and memos.
HBHS's Director of External Affairs will make the rquired changes. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations did not include a composite picture, assets/strengths, an evaluation of support systems and defense/coping mechanisms in five of five records reviewed, # 1, 2, 3, 4 and 5.
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Plan of Correction
Further training will be provided by Holcomb Behavioral Health Systems to all involved staff that will emphasise inclusion of assets/strengths, evaluation of supports systems, and defense/coping mechanisims in all future psychosocial evaluations.The Clinical Supervisor will be responsibile for this training.
Date of Completion: 3-01-07 |
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:
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Observations
Treatment plans were late (not completed according to facility policy) in three of five records reviewed, # 2, 4 and 5.
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Plan of Correction
Further training will be provied by Holcomb Behavioral Health Systems to all involved staff to ensure timely completion of all Treatment Plans.
The Clinical Supervisor will be responsible for monitoring this process.
Date of Completion: 3/01/07 |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Treatment plan goals did not include measurable actions steps for all goals in three of five records reviewed, # 3, 4 and 5.
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Plan of Correction
Further training will be provided by Holcomb Behavioral Health Systems to all involved staff to ensure that all Training Plans include measurable action steps for all goals.
The Clinical Supervisor will monitor this process.
Date of Completion: 3/01/07 |
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 did not include support services, a contact person or the re-entry process in two of two records reviewed, # 6 and 7.
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Plan of Correction
Additional training will be offered by Holcomb Behavioral Health Systems to all involved staff to ensure that all aftercare plans include support services, a contact person, or the re-entry process for discharged clients. The Clinical Supervisor will monitor this process.
Date of Completion: 3/01/07 |