INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on March 20, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on April 20, 2007.
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Plan of Correction
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709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The personal history included minimal details regarding the client's family history and did not allow for any insight into the client's family of origin in two of two client records reviewed, #1 and 2. The personal history included minimal details regarding the client's sexual history. Specifically, the sexual history was missing the age of the client's first sexual experience and whether the client experienced any sexual dysfunction in two of two client records reviewed, #1 and 2.
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Plan of Correction
Personal histories were missing specific information regarding sexual history and family origin. The program will be in full compliance by 7/15/07 by revising the personal history report to include more specific questions relating to family and sexual history. The executive director will ensure, supervise and train staff to complete the revised paperwork and monitor the completeness of histories. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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
Treatment plans were not individualized in two of two client records reviewed, #1 and 2.
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Plan of Correction
Treatment plans were missing individuality because of how the reports describe objectives and goals generally and lack specificity. When compared to each other they can look similar. By 7/15/07, the program will be in full compliance by changing the documentation to include individualized plans. Clients will be engaged and asked to write down areas of treatment needed along with the counselor. This will ensure individuality of reports. The executive director will ensure, supervise and train staff to complete the revised paperwork and monitor the change in treatment plans. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
An emergency telephone number was not displayed to the general public.
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Plan of Correction
An emergency telephone number was not displayed with all other public information. By 4/20/07, the executive director will ensure and monitor that the emergency number will be added to the sign on the front door of the center. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The personal history included minimal details regarding the client's family history and did not allow for any insight into the client's family of origin in two of two client records reviewed, #3 and 4. The personal history included minimal details regarding the client's sexual history. Specifically, the sexual history was missing the age of the client's first sexual experience and whether the client experienced any sexual dysfunction in two of two client records reviewed, #3 and 4.
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Plan of Correction
Personal histories were missing specific information regarding sexual history and family origin. The program will be in full compliance by 7/15/07 by revising the personal history report to include more specific questions relating to family and sexual history. The executive director will ensure, supervise and train staff to complete the revised paperwork and monitor the completeness of histories. |
709.92(a) 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:
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Observations
Treatment plans were not individualized in two of two client records reviewed, #3 and 4.
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Plan of Correction
Treatment plans were missing individuality because of how the reports describe objectives and goals generally and lack specificity. When compared to each other they can look similar. By 7/15/07, the program will be in full compliance by changing the documentation to include individualized plans. Clients will be engaged and asked to write down areas of treatment needed along with the counselor. This will ensure individuality of reports. The executive director will ensure, supervise and train staff to complete the revised paperwork and monitor the change in treatment plans. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
An emergency phone number was not displayed to the general public.
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Plan of Correction
An emergency telephone number was not displayed with all other public information. By 4/20/07, the executive director will ensure and monitor that the emergency number will be added to the sign on the front door of the center. |