INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 29, 2006 through June 30, 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 24, 2006.
|
Plan of Correction
|
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.
|
Observations
Training feedback was not completed for all external training attended.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(a)(1) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(1) Recruitment, selection, promotion and termination of staff.
|
Observations
The policies and procedures for the recruitment and selection of staff did not indicate how job openings will be made known to potential candidates or who would interview and select candidates.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
|
Observations
The clinical records were stored in unlocked containers.
|
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.
|
Observations
The psychosocial evaluation did not evaluate the following areas: strengths/assets, support systems, and negative factors that may inhibit treatment in seven of eight clinical records reviewed, # 2, 3, 4, 5, 6, 7, and 8.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
Discharge summaries did not include the client's reason for treatment, services offered and the client status in five of seven clinical records reviewed, # 5, 9, 10, 11, and 12.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |