INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 13 through 14, 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 7, 2006.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training 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:
(2) An overall plan for addressing these needs.
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Observations
The overall training plan for 2006 did not include possible trainers and proposed dates of training.
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Plan of Correction
The Clinical Director will review staff input to training needs during a clinical staff meeting on November 21, 2006. The Clinical Director will then compile a written training plan including potential trainers and training dates which will be posted for staff review by January 1, 2007. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Feedback forms were not consistently documented in 5 of 5 records.
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Plan of Correction
The Clinical Director will review this standard during a July 11, 2006 clinical staff meeting. The clinical staff will receive instruction on proper procedures for completing feedback forms and compare previously written forms to the actual standard. The Clinical Director will monitor compliance to this process by monthly records reviews. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Information was released without consent in one of 13 records reviewed, specifically #4.
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Plan of Correction
The Clinical Director will meet with the Intake Coordinator and the clinical staff during a July 11, 2006 clinical staff meeting. During this meeting the Clinical Director will review the standard and instruct the staff members on the correct procedure in filling out confidentiality forms. The Clinical Director will monitor compliance through weekly chart reviews. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Treatment plan updates did not include a review of progress on previously stated goals in 6 of 6 records reviewed.
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Plan of Correction
The Clinical Director will revise the treatment plan update form to include a progress statement space for each goal. The Clinical Director will train and review this new form with the clinical staff during a July 11, 2006 clinical staff meeting. The Clinical Director will monitor compliance to the new form through weekly supervision and weekly record reviews. |
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
The medication records did not include the client's dosage or frequency of use in 3 of 3 records reviewed.
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Plan of Correction
The Clinical Director will revise the intake form to specifically include medication dosage and frequency on the first client contact. The Clinical Director will revise the medication record form to include medication dosage and frequency as to monitor it during the client's stay. The Clinical Director will review these two new forms with the Intake Coordinator and the clinical staff during a July 11, 2006 clinical staff meeting and with the Managers during a July 5, 2006 Manager's meeting. The Clinical Director will monitor compliance with this procedure through weekly record reviews of the intake forms and weekly medication log reviews. |
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 documented summary of discussion was insufficient and did not validate the disposition in 4 of 6 records reviewed.
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Plan of Correction
The Clinical Director will change the disposition section of the case consultation form to a summary of the discussion. The Clinical Director will review the revised form with the clinical staff during a July 11, 2006 clinical staff meeting. Included in this review will be proper completion of the revised section to comply with the standard. The Clinical Director will monitor compliance during weekly record reviews. |