INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 26, 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 1, 2007.
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Plan of Correction
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
A drug and/or alcohol history was not completed in one of three client records reviewed, #1.
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Plan of Correction
All bio-psychosocials administered by the counselor will have complete drug & alcohol histories. The Clinical Supervisor will review and initial all bio-psychosocials to ensure proper completion. |
709.92(a) 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:
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Observations
Comprehensive treatment plans were not individualized in three of three records reviewed.
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Plan of Correction
All treatment plans will contain documentation that refers to the bio-psychosocial which will individuate client treatment plans. Treatment plans will identify, address and contain specific problems unique to the client.
Treatment plans will be reviewed by the counselor and Clinical Supervisor to ensure compliance. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The treatment plans contained short and long term goals which were not clearly defined and/or lacked measurable action steps with time frames.
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Plan of Correction
Treatment plans will clearly identify short and long term goals. The Clinical Supervisor has instructed the counselor in the distinction and formulation of such goals with client input.
The counselor will review each treatment plan with the Clinical Supervisor. |
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
The treatment plans failed to include the proposed types of support services in three of three client records reviewed.
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Plan of Correction
Client and Counselor identify support services such as bi-weekly group therapy and attendance/paricipation in self-help groups. All individual counseling notes will document such services.
The Clinical Supervisor will ensure compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Two of three treatment plan updates were not individualized, #1 & 2.
Three of three treatment plan updates lacked a report on the client's progress relative to the previous goals.
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Plan of Correction
Treatment plan updates will be written on or around the fourth week of the eight week program. Counselor will document a Treatment Plan Update which will be reviewed by the Clinical Supervisor. |
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
Progress notes in three of three records reviewed did not include any plan other than for the client to continue to share with the counselor and group.
Individual progress notes often made reference to group sessions rather than provide clear assessments and plan for future treatment sessions.
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Plan of Correction
All individual progress notes will provide only the assessment for each particular session.
The Clinical Supervisor will review with the counselor, the appropriate DAP format for individual counseling notes.
The Clinical Supervisor will review, monitor, and ensure compliance. |
709.93(a)(6) 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:
(6) Individual treatment and rehabilitation plan.
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Observations
Case consults were not completed in one of one records reviewed.
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Plan of Correction
All clients will have documented at least one Case Consult during the treatment experience, which will be presented to the Clinical Supervisor for his review. Such consults will be completed during the fourth week of treatment.
Clinical Supervisor will ensure compliance. |