INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 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 July 14, 2006.
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Documentation did not support that alternate exits were used during fire drills at any time during the past year. An alternate exit must be utilized at least once during the year and the use must be documented in the fire drill documentation presented at the time of the licensing inspection.
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with fire safety requirements. We will alternate between front and rear exits during fire drills. This will be documented and made available during inspection. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
The data collection and record keeping system did not permit efficient retrieval of all information pertinent to the licensing process. CIS information actually released to the SCA could not be retrieved so that a determination could be made regarding compliance with applicable confidentiality regulations. Inconsistent use of the computer software package by staff resulted in incomplete information appearing in some portions of client records. The agency maintains a waiting list which results in clients being admitted, in some cases, up to two months prior to the actual commencement of counseling services on an individual basis. The result of this is that timelines are not followed for completion of various portions of the client record in adherence to agency policy.
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Plan of Correction
CIS information is transmitted to the SCA via the DOS based CIS program. This program only allows pertinent and permitted information to be transmitted. Due to recent software upgrades at our office we were unable to sufficiently document this to the licensing inspector. However, after further review we are confident that the information being transmitted to the SCA is only what is permitted and required by the CIS system. We are prepared to demonstrate this at our annual licensing visits.
In addition, Crossroads Counseling, Inc. is now fully staffed and we have no waiting list. We intend to follow through with all licensing regulations and follow through with all agency policies regarding timelines for completion of client records.
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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 were missed in two files (8 and 9). Files # 1, 2, 3, 5, 10 and 11 did not address coping mechanisms. The evaluation should provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all client record keeping requirements. Staff have been retrained on proper completion of psychosocial evaluations as well as the timelines in which they are to be completed. In addition, supervisors have bee re-trained to monitor client psychosocial evaluations to assure that they will be completed, be completed in a timely manner, and contain all of the required information, specifically including client coping mechanisms. The executive director, William Knecht, will oversee the clinical supervisors to assure that this is completed. This change will be implemented by 7/12/2006. |
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
Treatment plan updates did not consistently address progress on the client's goals as stated on the treatment plan. The computerized format utilized tended to use one or two word phrases ( "completed" or "in progress") to describe what occurred in the past sixty day period. The older type hand written updates did not consistently address the stated goals of the treatment plan in a systematic manner. One update was missing in file # 4.
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all treatment planning requirements. We recognize that treatment plan updates need to consistently address client's progress towards meeting their treatment plan goals. We had recently implemented a new software program to assist in treatment planning and unfortunately were not using the program to its full capabilities. The executive director, William Knecht, has spoken numerous times with the software manufacturer to ensure that it can produce satisfactory treatment plans and treatment plan updates. We are confident that it can and William Knecht has retrained the clinical staff and clinical supervisors on the proper way to complete treatment plan updates utilizing this software so that they client progress is sufficiently reviewed.
In addition, staff have been retrained on the proper way to complete the "older type, hand written updates" so that they consistently review the client's progress on their treatment plan reviews.
Clinical supervisors will review and sign off on all treatment plans to assure that they are being completed accurately.
These changes will be implemented by 7/12/2006. |
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
Some progress notes were missing in file # 11. Notes in file #1 did not consistently establish a therapeutic goal in the plan portion of the note. The plan (strategies) should reflect the counselor's actions to be taken in light of the evaluation and indicate the direction of treatment and include action steps, counselor plan(s) and client assignments or tasks.
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all requirements regarding proper completion of a client record. A clinical staff meeting was held to review progress note requirements and staff were reminded that they needed to complete all progress notes in a timely manner as well as well as reflect the counselor's actions to be taken in the plan section of the progress note. We recognize that this plan needs to reflect the counselor's actions to be taken in light of the evaluation and indicate the direction of treatment and include action steps, counselor plan(s) and client assignments or tasks. Clinical supervisors will review progress notes randomly as well as in regularly scheduled clinical supervision to assure accurate and timely completion. The Executive Director will oversee the clinical supervisors.
These changes will be implemented by 7/12/2006. |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
Client related correspondence appeared to be incomplete in files reviewed. In each file a number of consents to release information were found but no consistent documentation of information released was noted. Correspondence with the SCA, which was kept in the CIS system, could not be retrieved.
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all requirements regarding completion of a client record. All related correspondence is to be documented in the client chart. A copy of all written correspondence will be maintained in the chart. Verbal correspondence will documented in a casenote. A clinical staff meeting was held to review these requirements. Clinical supervisors will review client charts to assure that client related correspondence is accurately documented. The executive director will oversee the clinical supervisors.
These changes will be implemented by 7/12/2006. |