INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 27-29, 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 January 4, 2006.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
The designated clinical supervisor has not completed a core curriculum in clinical supervision. This was to be completed by 09/16/2004.
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Plan of Correction
We have had difficulty in finding a clinical supervision training locally and when we do the training is full. We have attempted to register, sent in the payment but we received our payment back due to the class being full.
We plan to:
1. The director will review trainings scheduled monthly by contacting BDAP for training schedule, the last week of each month.
2. The director will explore developing a training outline and submit it to the State for review and approval. If this is accepted we can provide the training ourselves. If we decide to submit a plan it will be submitted by January 20, 2007.
3. The director will contact a few local agencies that have state approved curriculum to offer clinical supervision training and request to have them conduct the training for our staff, (if state approves the request).
We have and will continue to make every attempt to have our clinical supervisor and chief counselor attend clinical supervision training as soon as we can. We are willing to send them we just have not be able to find a training that has openings for registration.
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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Employee #6 has not documented to the facility director that he is working toward counselor status.
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Plan of Correction
Employee number 6 will show progress in attaining state approved education that will allow the employee to be promoted to counselor within the staffing regulations time frame: (employee has four years left to obtain education)
1. Employee has been informed by Clinical supervisor of the citation
2. The clinical supervisor has informed/explained to employee number 6 what type of information is expected and needed from him to document that he is trying to obtain state approved education so he can be promoted to counselor status
3. The clinical supervisor will review all attempts to obtain a state approved degree/certificate on a monthly basis with the employee.
4. Failure of the employee to show attempts made for obtain education will result in the clinical supervisor using Progressive Medicals disciplinary procedure.
5. All of this information will be filed in the employee's personnel chart
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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
The short and long-term goals formulated in the individual treatment plan did not include specific details and were often repetitive in 11 out of 11 client records reviewed.
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Plan of Correction
Treatment planning appears to be difficult for the clinical staff, especially when focusing on developing specific steps to reach an attainable goal. As a result,
We plan to:
1. Develop an in house training for treatment planning that will include group work, samples, and case examples.
2. The clinical supervisors will hold a weekly training every Thursday for a 6-week period with all counselors/counselor assistants. This will begin January 4, 2007.
3. The trainings will be geared to help the clinical staff identify, develop and use attainable treatment plan goals with specific steps to reach these goals
4. The clinical supervisors and director will create a new treatment plan form to assist the clinical staff is developing attainable treatment plans. This form will be completed by the 3rd of January so it can be used in the training
5. The clinical supervisors will continue to review and sign treatment plans but will return treatment plans that are not specific to the client without a signature to the counselor/counselor assistant to redo.
6. We will look for local trainings for treatment planning skills and send clinical staff
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Proposed support services documented on the individual treatment plan were limited to AA/NA groups in 11 out of 11 client records reviewed.
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Plan of Correction
The individual treatment plans were corrected prior to the inspector's completion of the visit.
The treatment plan had other types of support services listed but the staff did not use them because they did not give a client a written referral specific to one of the support service categories.
As a result, the director held a meeting with all clinical staff, informed them that any type of service that they believe would be a benefit to the client is to be to circled on the treatment plan form as well as to add any support services that are not already listed. They were told that a written referral did not have to be given for that support service.
We had updated the treatment plan, adding additional types of support services.
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