INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 4, 2007 through June 5, 2007 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 5, 2007.
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Alternate exit routes were not documented in the fire drill log from July of 2006 through May of 2007.
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Plan of Correction
P281 705.28 The individual responsible for conducting fire drills was not familiar with the aspect of the regulation that required alternate exit routes to be utilized. The project will be in full compliance with this standard by July 31, 2007. The office coordinator will be trained in appropriate fire drill procedures. The Associate Director will review the regulations regarding fire drills in a face to face meeting with the office coordinator to ensure complete understanding of all requirements. The office coordinator will be instructed that all future fire drills must include the use of alternate exits and that the use of alternate exits must be documented in the fire drill log. The associate director will periodically review the fire drill log to ensure that alternate exits are utilized and documented. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Drug and alcohol histories did not address the client's length and patterns of abuse in seven of eight records reviewed, #2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
1863 709.91(b)(3)(ii) Counselors believed themselves to be documenting complete drug and alcohol histories. However, upon review, it is acknowledged that drug and alcohol histories, as documented with the use of the DENS ASI tool need to be more complete. The clinical supervisor and program director will hold a meeting with counselors to ensure that they have a full understanding of how to develop a complete drug and alcohol history, including documentation of client's length of use and patterns of use, as well as how to use the DENS ASI software to collect and print a more detailed drug and alcohol history. The counselors will be responsible to fully develop and document the client's drug and alcohol history and the clinical supervisor will review all charts to ensure that counselors are in compliance with this standard. This correction will be in place by July 31, 2007. |
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 histories failed to address family relations, employment and sexual histories in eight of eight records reviewed,# 1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
1865 709.91(b)(3)(iii) Counselors believed themselves to be documenting complete personal histories. However, upon review, it is acknowledged that personal histories, as documented with the use of the DENS ASI tool, need to be more complete. The clinical supervisor and program director will hold a meeting with counselors to ensure that they have a full understanding of how to develop a complete personal history, including documentation of client's family relations, sexual history and employment history. This training will also include use of the DENS ASI more efficiently to collect and document a thorough personal history. The counselors will receive additional training on the need to develop and document personal histories, including specifically the three above-listed areas. The counselors will be responsible to fully develop and document the client's personal histories and the clinical supervisor will review all charts to ensure that counselors are in compliance with this standard. This correction will be in place by July 31, 2007. |
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
Psychosocial evaluations were missing in two of eight records reviewed, #7 and 8. The psychosocial evaluation was historical rather than evaluative in client record #1. Client assets and strengths were not included in six of eight client records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
709.91(b)(6) Counselors failed to print two of the psychosocial evaluations from the computer-generated format in two of eight records. Counselors did not fully comprehend the need to synthesize the factual information gathered in the assessment into a clinical evaluation and impression. Counselors failed to include clients' strengths and assets because the DENS ASI addendum, which prompts counselors to include this information, was not consistently utilized. The clinical supervisor and program director will hold a training with counselors to ensure that they have a full understanding of the need to synthesize data gathered during the assessment into a psychosocial evaluation and impression, including the therapist's assessment of the clients strengths, resources, problems, needs, as reflected by the history. The counselors will be responsible to fully develop and document their assessments in an evaluative rather than simply a historic manner. The counselors will be required to consistently utilize the DENS ASI Addendum form for all clients. The clinical supervisor will review all charts to ensure that counselors include documentation and consideration of clients' strengths and assets in their evaluations and that all records are in compliance with this standard. This correction will be in place by July 31, 2007. |
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 plans failed to include realistic and measurable goals in four of four records reviewed, #5, 6, 7 and 8.
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Plan of Correction
1907 709.93(2)(9) After further review of aftercare planning documents, it was determined that counselors need to be more consistent in the formulation of aftercare plans including realistic and measurable goals and time frames. The clinical supervisor and program director will hold a meeting with counselors responsible for developing aftercare plans to ensure that counselors understand the need to develop comprehensive and measurable aftercare plans, which include timeframes for goal achievement. The clinical supervisor and program director will hold a training with counselors to ensure the means of developing a comprehensive aftercare plan, how to work with clients to develop aftercare goals, and how to develop reasonable timeframes for achievement of aftercare goals. The clinical supervisor will thereafter review all client files upon discharge to ensure that aftercare plans are comprehensive, include reasonable and measurable goals and timeframes for achievement of those goals. Any failure by counselors to include all aspects will result in additional training for individual counselors members. This correction will be in place by July 31, 2007. |
709.44(a)(1)(ii) LICENSURE Drug/Alcohol history
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Drug and alcohol histories did not include the client's lengths and patterns of use and the clients perception of use in three of four client records reviewed, #1, 2 and 3.
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Plan of Correction
0675 709.44(a)(1)(ii) The records did not include documentation of comprehensive drug and alcohol histories in the scope and format required for documentation because the counselors did not collect the data in the manner and format required (see 1863 above). The clinical supervisor and the program director will meet with counselors to ensure that, in addition to a full understanding of the need to develop a comprehensive drug and alcohol history and the manner in which to do so, that counselors also document the drug and alcohol history in the clinical record. The clinical record will reflect the client's lengths and patterns of use, as well as the client's perception of use. This meeting will take place in July 2007 and corrective actions will be in place by July 31, 2007. The counselors will be responsible to document the complete drug and alcohol history; The clinical supervisor will be responsible to train the counselors, review the records and give feedback to counselors to ensure that they are completing and documenting the drug and alcohol history fully. |
709.44(a)(1)(iii) LICENSURE Personal history
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the following:
(iii) Personal history.
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Observations
The personal histories failed to address family relations, legal, employment/vocation and sexual histories in four of four client records reviewed, # 1, 2, 3 and 4.
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Plan of Correction
0677 709.44(a)(1)(iii) The client records did not always include personal histories that reflected family relations, legal , employment, vocational, and sexual histories, because the counselors were not fully developing these in the assessment (see 1865). This appeared to be because of a lack of clear understanding of the need to fully explore and document these areas. The clinical supervisor and the program director will meet with counselors to ensure that, in addition to a full understanding of the need to develop a comprehensive personal histories, including reflected family relations, legal, employment, vocational, and sexual histories. This training will also include the manner in which to do so and the importance that the fully developed personal history is clearly documented in the clinical record. This meeting will take place in July 2007 and corrective actions will be in place by July 31, 2007. The counselors will be responsible to document the complete personal history; The clinical supervisor will be responsible to train the counselors, review the records and give feedback to counselors to ensure that they are completing and documenting the personal history fully |
709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
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Observations
Psychosocial evaluations failed to include assets/strengths, support system and counselors impressions in three of four client records reviewed, #1, 2 and 3.
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Plan of Correction
0681 709.44(a)(3) Client records failed to include client assets, strengths, support systems, and counselor impressions, because therapist failed to print out the psychosocial evaluation included in the DENS ASI addendum in three cases reviewed. Counselors failed to include clients' strengths, assets, support system and counselor evaluation because the DENS ASI addendum, which prompts counselors to include this information, was not consistently utilized. The clinical supervisor and program director will hold a training with counselors to ensure that they have a full understanding of the need and method of printing out the full psychosocial evaluation and include it in the clinical record. The counselors will be responsible to fully develop and document their assessments in an evaluative rather than simply a historic manner. The clinical supervisor will review all charts to ensure that counselors include documentation and consideration of clients' strengths, assets, support system, and therapist impressions in their evaluations and that all records are in compliance with this standard. This correction will be in place by July 31, 2007 |