INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24, 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 June 18, 2007.
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Plan of Correction
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
The facility failed to secure client records within locked storage containers. Discharged records were stored in boxes in a storage room which was also an exit route.
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Plan of Correction
Discharged records being stored in a room that is also an exit route will be relocated to locked filing cabinets. Completion of this action step within 30 days will be monitored and verified by the Risk Manager. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Group progress notes did not include the data and plan portion of the note in four of four client records reviewed, #1, 2, 3 and 4.
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Plan of Correction
The facility director will oversee that all clinical staff are educated in a staff meeting to thoroughly complete the data and assessment portions of the progress notes. Ongoing monitoring will be conducted by the Director of Outpatient and Risk Manager to ensure that progress notes are completed in compliance with set standards. |
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
Aftercare plans did not include future goals with time frames or support services in two of two records reviewed, #3 and 4.
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Plan of Correction
The facility director will train clinical staff on the required components of the Aftercare plan and the need to include future goals with time frames for completion of goals and support services in the plan. The current aftercare format will be modified, and proper form protocol will be reinforced and the Director of Outpatient will assure compliance with standards through medical records audits. |
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.
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Observations
Feedback forms were not documented in two of two personnel records reviewed, #1 and 2.
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Plan of Correction
The Staff Development policy and procedure has been updated as follows:
Evaluations of all staff development/inservices activities must be completed by all participants. Internal training evaluations must be completed and submitted to the Staffing Coordinator within five (5) business days of the on-site training. Evaluations of external or off-site trainings and seminars must be completed by the participant and submitted to the Staffing Coordinator within 30 days of attending the training.
Evaluations forms will be distributed by the Staffing Coordinator to all participants at the beginning of all on-site trainings and will be distributed to off-site participants when notified they attended a training.
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