INITIAL COMMENTS
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This report is a result of a complaint investigation conducted from March 30 - June 1, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Abstinent Living at the Turning Point were substantiated. A plan of correction must be submitted by June 28, 2010.
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Plan of Correction
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709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the client handbook, policy and procedure manual, the program website and interviews with the project director and clients, the facility failed to develop complete written procedures for the management of treatment/rehabilitation services for clients including disciplinary actions for failure to follow the required eating/nutrition plan.
The findings include:
An interview with the project director and four clients took place on March 30, 2010. Based on these interviews, it was established that participation in an eating/nutrition plan is an integral part of treatment and a requirement for all clients at this program. It was also established that discipline is in place for clients who violate the eating/nutrition plan.
Reviews of the client handbook, policy and procedure manual and the program website took place on April 16, April 29, May 28 and June 1, 2010. The facility did not document the procedures regarding the eating/nutrition plan and the process of discipline in place for violations of the eating/nutrition plan.
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Plan of Correction
In Answer to 0159:
Clients are not permitted to take food to their bedrooms and are made aware that the facility will sanction if they don't comply to this rule.
As of 07/01/2010 all policies will be removed from the Policies and Procedure Manual, Handbook, and program website. The Facility will comply with Food Service Standards (709.57) of The Department of Health. The Clients will participate in the menu preparation. This will be overseen by the Business Manager and the Project Director.
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709.51(a)(1) LICENSURE Criteria for Admission
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
Based on a review of the client handbook, policy and procedure manual, the program website and interviews with the project director and clients, the facility failed to develop a complete written plan for providing for intake and admission which included reference to the eating/nutrition plan in the criteria for admission.
The findings include:
An interview with the project director and four clients took place on March 30, 2010. Based on these interviews, it was established that participation in an eating/nutrition plan is an integral part of treatment and a requirement for all clients at this program.
Reviews of the client handbook, policy and procedure manual and the program website took place on April 16, April 29, May 28 and June 1, 2010. The facility did not document a written plan for intake and admission which included the requirement of participation in an eating/nutrition plan as a criteria for admission.
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Plan of Correction
In Answer to 1731:
As of 07/01/2010 all policies will be removed from the Policies and Procedure Manual, Handbook, and program website. The Facility will comply with Food Service Standards (709.57) of The Department of Health. The Clients will participate in the menu preparation. This will be overseen by the Business Manager and the Project Director. |
709.51(a)(2) LICENSURE Treatment Methodology
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(2) Treatment methodology.
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Observations
Based on a review of the client handbook, policy and procedure manual, the program website and interviews with the project director and clients, the facility failed to develop a written plan for providing for intake and admission which included all of the treatment methodologies utilized at the program.
The findings include:
An interview with the project director and four clients took place on March 30, 2010. Based on these interviews, it was established that one of the treatment methodologies or types of treatment was participation in an eating/nutrition plan as an integral part of treatment and that it was a requirement for all clients at this program.
Reviews of the client handbook, policy and procedure manual and the program website took place on April 16, April 29, May 28 and June 1, 2010. The facility did not document participation in the eating/nutrition plan as one of the treatment methodologies.
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Plan of Correction
In answer to 1733:
As of 07/01/2010 all policies will be removed from the Policies and Procedure Manual, Handbook, and program website. The Facility will comply with Food Service Standards (709.57) of The Department of Health. The Clients will participate in the menu preparation. This will be overseen by the Business Manager and the Project Director. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on client interview and a review of the client handbook and program website, the facility failed to disclose to the client the criteria for admission, treatment, completion and discharge.
The findings include:
An interview with four clients took place on March 30, 2010. Based on these interviews, it was established that participation in an eating/nutrition plan is an integral part of treatment and a requirement for all clients at this program. Four out of four clients confirmed that they had not been provided with information regarding the eating/nutrition plan prior to admission and were unaware that it was a requirement of the program.
Reviews of the client handbook, policy and procedure manual and the program website took place on April 16, April 29, May 28 and June 1, 2010. The facility did not document any details of the eating/nutrition plan in the client handbook or on the program website.
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Plan of Correction
In answer to 1739:
As of 07/01/2010 all policies will be removed from the Policies and Procedure Manual, Handbook, and program website. The Facility will comply with Food Service Standards (709.57) of The Department of Health. The Clients will participate in the menu preparation. This will be overseen by the Business Manager and the Project Director. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on client interview and a review of the client handbook and program website, the facility failed to disclose to the client the project policies regarding the required participation in an eating/nutrition plan.
The findings include:
An interview with four clients took place on March 30, 2010. Based on these interviews, it was established that participation in an eating/nutrition plan is an integral part of treatment and a requirement for all clients at this program. Four out of four clients confirmed that they had not been provided with project policies regarding the eating/nutrition plan prior to admission and were unaware that it was a requirement of the program.
Reviews of the client handbook, policy and procedure manual and the program website took place on April 16, April 29, May 28 and June 1, 2010. The facility did not document any policies regarding the eating/nutrition plan in the client handbook or on the program website.
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Plan of Correction
In Answer to 1741:
As of 07/01/2010 all policies will be removed from the Policies and Procedure Manual, Handbook, and program website. The Facility will comply with Food Service Standards (709.57) of The Department of Health. The Clients will participate in the menu preparation. This will be overseen by the Business Manager and the Project Director. |
709.51(b)(2)(iv) LICENSURE Services Provided
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iv) Services provided.
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Observations
Based on client interview and a review of the client handbook and program website, the facility failed to disclose to the client a complete listing of services provided at the program, specifically, the required participation in a eating/nutrition plan.
The findings include:
An interview with four clients took place on March 30, 2010. Based on these interviews, it was established that participation in an eating/nutrition plan is an integral part of treatment and a requirement for all clients at this program. Four out of four clients confirmed that they had not been provided with a list of services including the participation in the required eating/nutrition plan prior to admission and were unaware that it was a requirement of the program.
Reviews of the client handbook, policy and procedure manual and the program website took place on April 16, April 29, May 28 and June 1, 2010. The facility did not document a complete list of services including the eating/nutrition plan in the client handbook or on the program website.
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Plan of Correction
In answer to 1747:
As of 07/01/2010 all policies will be removed from the Policies and Procedure Manual, Handbook, and program website. The Facility will comply with Food Service Standards (709.57) of The Department of Health. The Clients will participate in the menu preparation. This will be overseen by the Business Manager and the Project Director. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of the client handbook, policy and procedure manual, the program website and interviews with the project director and clients, the facility failed to document a health screening component to the medical history to ascertain fitness to participate in a eating/nutrition plan given that it is a requirement of the program.
The findings include:
An interview with the project director and four clients took place on March 30, 2010. Based on these interviews, it was established that participation in an eating/nutrition plan is an integral part of treatment and a requirement for all clients at this program.
Reviews of the client handbook, policy and procedure manual and the program website took place on April 16, April 29, May 28 and June 1, 2010. The facility did not document a health screening component to the medical history to ascertain fitness to participate in the required eating/nutrition plan.
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Plan of Correction
In answer to 1749:
As of 07/01/2010 all policies will be removed from the Policies and Procedure Manual, Handbook, and program website. The Facility will comply with Food Service Standards (709.57) of The Department of Health. The Clients will participate in the menu preparation. This will be overseen by the Business Manager and the Project Director. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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
Based on a review of the spring menu and twenty four treatment plan updates, the facility failed to document an individualized treatment and rehabilitation plan as all residents were required to participate in an identical eating/nutrition plan.
The findings include:
An interview with the project director and four clients took place on March 30, 2010. Based on these interviews, it was established that participation in an eating/nutrition plan is an integral part of treatment and a requirement for all clients at this program.
Reviews of the client handbook, policy and procedure manual and the program website and spring menu took place on March 20, April 16, April 29, May 28 and June 1, 2010. The facility failed to document participation in a eating/nutrition plan on the individualized treatment and rehabilitation plan on twenty four out of twenty four treatment plan updates reviewed. The spring menu was created and set prior to the beginning of the season. The menu is not individualized and is the same for all clients.
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Plan of Correction
In Answer to 1763:
Facility inadvertently put out spring menu too early this will be closely watched by the Operations Manager.
As of 07/01/2010 all policies will be removed from the Policies and Procedure Manual, Handbook, and program website. The Facility will comply with Food Service Standards (709.57) of The Department of Health. The Clients will participate in the menu preparation. This will be overseen by the Business Manager and the Project Director. |
709.54(a)(6) LICENSURE Special dietary needs
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(6) Special dietary needs.
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Observations
Based on a review of the client handbook, policy and procedure manual, the program website and interviews with the project director and clients, the facility failed to develop complete written policies and procedures providing for its dietetic services which include special dietary needs.
The findings include:
An interview with the project director and four clients took place on March 30, 2010. Based on these interviews, it was established that participation in an eating/nutrition plan is an integral part of treatment and a requirement for all clients at this program.
Reviews of the client handbook, policy and procedure manual and the program website took place on April 16, April 29, May 28 and June 1, 2010. The facility did not document written policies and procedures for its dietetic services which include special dietary needs. There is no documentation of policy and procedures in regards to the dietary needs of women with a history of addiction, various cultural and religious backgrounds, women of various sizes, individual preferences and medical concerns.
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Plan of Correction
In answer to 1831:
A Policy and Procedure was written that will include special dietary needs. Facility will purchase any special dietary needs for individual religious beliefs, cultural backgrounds, medical issues, vegetarians, vegans, etc. This is overseen by the Project Director. And was put in the Policies and Procedures on 06/18/10 page 100 under Treatment Methodology by the Business Manager.
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