INITIAL COMMENTS
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This is a report of the on-site licensure renewal inspection conducted on January 2 through 4, 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 February 2, 2007.
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Plan of Correction
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704.8(a) LICENSURE Qualifications-Counselor Assistant
704.8. Qualifications for the position of counselor assistant.
(a) A person who does not meet the educational and experiential qualifications for the position of counselor may be employed as a counselor assistant if the requirements of at least one of the following paragraphs are met. However, a project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
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Observations
The facility currently has seven counselor assistants and only two full time clinical supervisors and two full time counselors.
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Plan of Correction
The Directors of outpatient and residential services have reviewed the counselor regulations again as of 1/16/07. We have transferred one of the counselor assistants to another location. This has brought our ratio to 2 clinical supervisors and 2 counselors and 5 counselor assistants. As of 2/27/07 a counselor assistant will have obtained their 1 yr experience and become a counselor. This will bring our ratio to 4 and 4 effective 2/27/07. Our plan is to fill the vacated position with a qualified counselor within the next 60 days. We are increasing our focus on staff development to assist in retention of our counselors to help reduce the turnover rate. The first in-service occurred 1/19/07. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Information was release to VBH without a consent to release in two of fifteen client records, #2 and 3.
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Plan of Correction
Certain staff members had misread the VBH consent form re: grievances and thought that it was a consent to release information. They were addressed on this 1/5/07 and the lead LPN re-educated the staff on the importance of completing accurate and appropriate consents. This is considered resolved as of 1/16/07. This will be moitored on an ongoing basis by the Director of Residential Services throughout chart auditing. |
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.
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Observations
The discharge summary was missing in one of two client records, #14.
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Plan of Correction
The director of OP services met with the appropriate counselor to discuss time frames surrounding discharge summary completion. This will also be reinforced to all counselors in a counselor inservice scheduled for 1/19/07. The director of OP services will monitor via random chart audits to ensure compliance |