INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 13, 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 August 15, 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 plan for addressing training needs for the 2006 training year (January to December) was missing.
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Plan of Correction
The Project Director will create the training plan. It will be completed annually, and be presented to the managers annually.
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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 plan was missing for the 2005 training year.
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Plan of Correction
An overall evaluation for the 2005 training plan was compiled by the Director Tom Whiteman, using the individual evaluations from each of the therapists. For 2006 Tom Whiteman will use the evaluations collected from each individual therapist to compile a summary of the overall evaluation of the training plan. |
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
Employee # 22 has not received HIV/AIDS and TB/STD training.
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Plan of Correction
Employee #22 was told they must produce documentation of HIV/AIDS and TB/STD training. If they are unable to produce proof of completion they must attend the HIV training at Eagleville Hospital September 7, 2006 9am-4pm or December 14, 2006 9am-4pm. They must also attend the TB/STD training at Eagleville Hospital November 2, 2006 9am-4pm. They will bring back the certificate and submit it to Tom Whiteman no later than 1 week after the training. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
The female bathroom does not have an operational exhaust fan.
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Plan of Correction
Staff will notify the landlord of the fan being broken and request work be completed within 30 days |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The project goals and objectives did not identify any available resources.
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Plan of Correction
The goals and objectives will be created each year by the Project Director who will ensure that they will include the available resources or responsible personnel.
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
A written agreement for 24-hour emergency psychiatric and medical coverage was not provided.
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Plan of Correction
A revised referral agreement will be sent to Belmont hospital. It will include the 24 hour emergency psychiatric and medical coverage agreement. |
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
Parent/guardian signature lines were included on the consent to release information forms. Parental consent for disclosure of information is not mandated by state law and cannot be required.
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Plan of Correction
A new release form with parent's signature removed was created |
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
The psychosocial evaluations did not assess the client's assets/strengths, support systems, coping mechanisms, and negative factors that may inhibit treatment in five of five client records reviewed, # 1, 2, 3, 4 and 5.
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Plan of Correction
Each site manager will have a staff training by September 30, 2006 which will address the following objective:
Creating an accurate psychosocial which includes strengths, weaknesses, support systems, coping mechanisms and risk assessment. Staff will submit to the manager 3 psychosocial evaluations for review by October 15, 2006. The manager will continue to review 3 charts on monthly basis and give individual feedback to each therapist. |
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
Goals did not contain measurable action steps in four of five client records reviewed, # 1, 2, 3 and 5.
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Plan of Correction
Each site manager will have a staff training by September 15, 2006 which will address the following objectives:
Creating a treatment plan which has measurable goals with related action steps, and a review process of those goals from previous treatment plans
Each staff person will submit 3 charts for review by October 1, 2006. The manager will review to verify completion of treatment plan updates as well as for content of update. Content should include a review of client's goals and action steps from the treatment plan.
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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 include a review of the client's progress on goals and action steps from the previous treatment plan in four of six client records, # 1, 2, 3 and 4.
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Plan of Correction
Each site manager will have a staff training by September 15, 2006 which will address the following objectives:
How to review goals and action steps from previous treatment plans
Each staff person will submit 3 charts for review by October 1, 2006. The manager will review to verify completion of treatment plan updates as well as for content of update. Content should include a review of client's goals and action steps from the treatment plan.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Case consultations were missing in three of five client records reviewed, # 1, 2 and 3.
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Plan of Correction
Site managers will randomly evaluate 3 charts from each therapist on a monthly basis. The evaluation will focus on objectives of the charting training as well as ensuring that a case consultation note is present for each date of service.
Therapists who do not have charts which are in compliance will be placed on probation. 3 failed chart reviews will be cause for dismisal. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Follow up information was not documented in three of four client records reviewed, # 6, 7 and 8.
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Plan of Correction
Site managers will randomly evaluate 3 charts from each therapist on a monthly basis. The evaluation will focus on verification that follow up information was documented.
Therapists who do not have charts which are in compliance will be placed on probation. 3 failed chart reviews will be cause for dismisal. |