INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29, 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 31, 2006.
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Plan of Correction
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Disclosures of information exceeded the type and amount of information to be disclosed that was listed on the signed consents on file.
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Plan of Correction
Staff have failed, in certain cases, to properly identify the approved application of Act 126 provision.
Pathway to Recovery Clinical Supervisors will review outcome of annual site visit and confidentiality standards with the addiction counselors during a staff meeting on July 17, 2006 from 9:00 - 11:00 AM. Any client after July 17, 2006 implementation date will reflect compliance with regulation. The Clinical Supervisor will follow up and monitor to ensure ongoing compliance with regulations. The Facility Director and Clinical Supervisor will offer two trainings on confidentiality to be completed by October 30, 2006
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Proposed types of support services were not consistently documented in files reviewed . Examples of such services are: medical, psychiatric or psychological services, economic, legal, AA, and NA.
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Plan of Correction
Staff have not fully considered the broad spectrum of support service possibilities.Pathway to Recovery Clinical Supervisors will review outcome of annual site visit and documentation standards with the addiction counselors during a staff meeting on July 17, 2006 from 9:00 - 11:00 AM. Any client after July 17, 2006 implementation date will reflect compliance with regulation.
The addiction counselors will complete a documentation training specifically addressing the need for providing the support services information on the assessment, treatment plan and discharge summary. The Facility Director and Clinical Supervisor will provide two document trainings regarding implementation of documentation of support services, attendance will be mandatory of the addition counselor to be completed by October 30, 2006. The Clinical Supervisor will follow up and monitor by completing chart audits to ensure quality compliance.
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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
The plan portion of the note did not consistently set a goal for the next counseling session. 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
Staff have not, on occasion, goven due weight to the documentation of the plan for next session. The Clinical Supervisor will review the standards set for the progress notes which should include data, assessment and plans relative to treatment. The Clinical Supervisor will provide explanation of the information that should be included in the plan section of the progress note and will include a set goal for the next counseling session during a staff meeting on July 17, 2006 from 9:00 -11:00 AM. Any client after the July 17, 2006 implementation date will reflect compliance with regulation. The Clinical Supervisor will follow and monitor with chart audits to ensure compliance. |