INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 10, 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 September 12, 2006.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
The policies and procedures did not identify the person responsible nor the timeframe for the completion of the required components.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The individual training plans for all new hires were not completed within 30 days of the employee's hire date.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.81(b)(6) LICENSURE Intake and admission
709.81. 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, and negative factors that may inhibit treatment in one client record, # 16.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Counseling services were not provided according to the treatment plan in the partial hospitalization client record, #16.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
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Observations
The policy does not indicate that the project director may temporarily remove portions of the records prior to the inspection by the client.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
A policy and procedure addressing the client's right to appeal this decision was not addressed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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, and negative factors that may inhibit treatment in three of seven client records reviewed, #1, 3 and 7.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
The aftercare plan does not include a contact person or phone number for the client to call to begin the re-entry process. Goals and timeframes did not include specific information for the clients in three of seven client records reviewed, # 5, 6 and 15.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |