INITIAL COMMENTS
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This is a report of the on-site licensure renewal inspection conducted on July 4 through 8, 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 6, 2007.
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Plan of Correction
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Work performance evaluations were missing as required in two of two employee records reviewed, # 4 and 5.
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Plan of Correction
The Clinical Supervisor and Program Director will see that the performane evaluations that are late will be completed by July 5, 2007. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Preliminary treatment plans were missing in three of seven client records reviewed, # 1, 2 and 6.
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Plan of Correction
The Clinical Supevisor will instruct all clinical staff of the importance of completing a preliminary treatment plan on all clients following the initial intake session.
This information was given to staff in memo on June 7th and in a staff meeting on the 11th. |
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
Support services were missing on treatment plans in three of seven client records reviewed, # 1, 2 and 9.
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Plan of Correction
The Clinical Supervisor will remind staff to document the support services that client's are using.
The Clinical Supervisor reminded staff of the above issue during the staff meeting on June 13th. |