INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6, 2007 through March 21, 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 April 13, 2007.
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Plan of Correction
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INITIAL COMMENTS
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709.14 Restriction on License (a)(5) Authorized capacity
Facility has a census of 76 for the outpatient drug free activity which exceeds the authorized maximum capacity of 70.
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Fire drills were not conducted for four out of the last twelve months, 7/06, 8/06, 11/06 and 2/07.
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Plan of Correction
705.28 (d)(1) Safety Officer failed in documenting the drills for 07/06, 8/06 and 2/07. Drills were conducted. Safety Officer will follow prescribed documenting procedures and comply with the standard. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Fire drills were not conducted at different times of the day and on different staffing shifts. The facility's hours range from 8:00 a.m. to 7:00 to 9:00 p.m. in the evening. Fire drills were conducted between 1:00-2:00 p.m. No fire drills were conducted before 1:00 p.m. or after 4:00 p.m.
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Plan of Correction
705.28(d)(6) Safety Officer will adjust schedule of evacuation drills to comply with standard. 4/30/07 |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The type and frequency of services provided were not documented on treatment plans in three of four client records reviewed, #1, 3 and 4.
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Plan of Correction
709.82 (a)(2) When an individual treatment plan is completed on a patient the type and frequency of services provided will be documented on the treatment plan. The director reviewed this procedure with the clinical staff. This will be monitored by the Director via monthly chart reviews. 3/30/2007 |
709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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
The comprehensive treatment plan did not contain support services based on client needs in three of four client records, #1, 3 and 4.
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Plan of Correction
709.82(a)(3) All individual treatment plans will include proposed types of support services. This will include legal, 12 step support groups etc. The director reviewed how this procedure should be documented on the treatment plan with all clinical staff. This will be monitored by the Director via monthly chart reviews. 3/30/2007 |
709.82(d)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(2) Group counseling, at least twice weekly.
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Observations
Group sessions were not conducted twice a week as stated on treatment plans in three of four records reviewed, #1, 2 and 3.
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Plan of Correction
709.82(d)(2) Group sessions that are documented on the treatment plan will be consistent with the groups conducted each week for the patient. Director reviewed this procedure with all clinical staff. This will be monitored by the director during monthly chart reviews. 3/30/2007 |
709.83(a)(9) LICENSURE Client records
709.83. 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) Progress notes.
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Observations
Progress notes did not evaluate or assess the client's progress during treatment in three of four records reviewed, #1, 2 and 3.
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Plan of Correction
709.83 (a)(9) All Progress notes will evaluate or access the clients progress during treatment. The director reviewed the procedure with all clinical staff. This will be monitored by the director during monthly chart reviews.03/30/2007 |
709.84(d) LICENSURE Project management services
709.84. Project management services.
(d) The project shall develop a written client aftercare policy.
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Observations
The aftercare policy did not include when the plan is created and who is responsible for the completion of the plan.
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Plan of Correction
709.84(d) An aftercare policy was developed. The policy includes all aftercare plans will be completed by the Addiction Counselor with patient on the patient's discharge date. The director reviewed this procedure with all clinical staff. The director will monitor this via monthly chart reviews. 03/30/2007 |
709.84(e) LICENSURE Project management services
709.84. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
A follow up policy was not in place.
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Plan of Correction
709.84 (c ) A follow-up policy (policy number RDP4016) was developed and reviewed with all clinical staff by the Director. The director will monitor this via monthly chart reviews. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The type and frequency of services provided were not documented on treatment plans in five of eight client records reviewed, #1, 4, 5, 7 and 8.
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Plan of Correction
709.82 (a)(2) When an individual treatment plan is completed on a patient the type and frequency of services provided will be documented on the treatment plan. The director reviewed this procedure with the clinical staff. This will be monitored by the Director via monthly chart reviews. 3/30/2007 |
709.94(d) LICENSURE Project management services
709.94. Project management services.
(d) The project shall develop a written client aftercare policy.
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Observations
The aftercare policy did not include when the plan is created and who is responsible for the completion of the plan.
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Plan of Correction
709.84(d) An aftercare policy was developed. The policy includes all aftercare plans will be completed by the Addiction Counselor with patient on the patient's discharge date. The director reviewed this procedure with all clinical staff. The director will monitor this via monthly chart reviews. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
A follow up policy was not in place.
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Plan of Correction
709.84 (c ) A follow-up policy (policy number RDP4016) was developed and reviewed with all clinical staff by the Director. The director will monitor this via monthly chart reviews. |