INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5 through 6, 2006 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 January 5, 2007.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Documentation of weekly supervision from August through October 2006 was not provided for employee # 9.
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Plan of Correction
The clinical supervisor will reveiw the counselor assistant's progress notes and treatment plans on a weekly basis. The clinical supervisor will continue to document individual supervision sessions with assistant counselors and note needed corrections. The clinical supervisor will also sign off on all individual group notes and treatment plans and co-sign aftercare approval. |
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
Clients signed blank consent to release information forms in three of three clinical records reviewed for the Transitional Living Facility, # 3, 4 and 7.
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Plan of Correction
The Transitional Living Facililty Coordinator will assure that all required informtaion is noted in disclosure forms prior to the client's signature and authorization. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
The client rights were missing in seven of seven clinical records reviewed, # 1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
Intake personnel will ensure that all clinical files contain client's rights and are reviewed with all incoming clients during the intake process. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations were incomplete. Specifically, support systems were missing in eight of eleven clinical records reviewed, #1, 2, 4, 5, 8, 9, 10 and 11. Coping mechanisms were missing in eleven of eleven clinical records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11.
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Plan of Correction
All clinical counselors were informed by the clinical supervisor to include a narrative referring to family support systems and individuals who give positive support as well as adverse relationships that can effect relapse behaviors. The clinical supervisor,within 72 hours of the client's admission, will review all submitted biopsychosocials to insure that each evaluation has specific information related to the client's coping mechanisms, strengths and weaknesses and the interventions to be used to address treatment needs. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Treatment plan updates were missing in two of eleven records reviewed, # 1 and 4. The treatment plan updates did not review the client's progress on goals in four of nine clinical records reviewed, #2, 5, 6 and 8.
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Plan of Correction
The clinical supervisor will insure that treatment plan updates are completed every 30 days with specific progress information needed for new interventions and addressing specific needs and problem areas of all clients. All counselors have been made aware of this by the clinical supervisor. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
The record of services was missing in six of eleven clinical records reviewed, # 3, 4, 5, 7, 9 and 10.
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Plan of Correction
All counselors were informed by the clinical supervisor that all clinical files must contain record of treatment activities. The clinical supervisor will review all clinical files bi-weekly to ensure that all client participation activities are noted in the chart along with the date, time and initials. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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:
(8) Case consultation notes.
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Observations
Case consultation notes were missing in four of four clinical records reviewed, #1, 2, 10 and 11.
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Plan of Correction
Case consulation notes will be completed by counselor as per the clinical supervisor's review and consultation of treatment needs, infractions and sanctions imposed and continued treatment needs. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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 plan was missing in one of two clinical records reviewed, #10. The aftercare plan was missing a contact person and the reentry process in one of one clinical record reviewed, #11.
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Plan of Correction
The clinical supervisor has advised all counselors that aftercare plans must be completed in all discharge summaries noting the name of the facility being referred to, appointment date and time.
The clinical supervisor will review all submitted discharge reports to ensure that they include an aftercare plan, contact person, place of aftercare, date of appointment and any medications that the client is taking in inpatient treatment. |