INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 27, 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 August 21, 2006.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
The overall plan for addressing training needs for the 2006 training year, January through December, was missing.
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Plan of Correction
The Project Director will create the training plan. It will be completed annually, and be presented to the managers annually. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
The annual evaluation of the overall plan was missing for the 2005 training year.
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Plan of Correction
An overall evaluation for the 2005 training plan was compiled by the Director Tom Whiteman, using the individual evaluations from each of the therapists. For 2006 Tom Whiteman will use the evaluations collected from each individual therapist to compile a summary of the overall evaluation of the training plan |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
An alternate procedure has been approved by the Department, however, documentation that a smoke detector or fire alarm was inspected and operational was not provided as required.
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Plan of Correction
Effectively immediately, when Guy Murray submits the fire drill logs on the second Friday of every month they must include documentation paperwork from the fire alarm inspection company and when the fire alarm or smoke detector was tested for that month. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The project goals and objectives did not identify any available resources.
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Plan of Correction
The goals and objectives will be created each year by the Project Director who will ensure that they will include the available resources or responsible personnel.
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
A written agreement for 24-hour emergency psychiatric and medical coverage was not provided.
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Plan of Correction
A revised referral agreement will be sent to Main Line hospitals. It will include the 24 hour emergency psychiatric and medical coverage agreement. |
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
Parent/guardian signature lines were included on the consent to release information forms. Parental consent for disclosure of information is not mandated by state law and can not be required.
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Plan of Correction
A new release form with parent signature removed was created. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations did not assess the client's assets/strengths, support systems, coping mechanisms, and negative factors that may inhibit treatment in three of four client records, # 1, 3, and 4.
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Plan of Correction
Each site manager will have a staff training by September 30, 2006 which will address the following objective:
Ħ Creating an accurate psychosocial which includes strengths, weaknesses, support systems, coping mechanisms and risk assessment
Staff will submit to the manager 3 psychosocial evaluations for review by October 15, 2006. The manager will continue to review charts on monthly basis and give individual feedback to each therapist.
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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
Treatment plans goals did not contain measurable action steps in three of four client records reviewed, # 1, 3, and 4.
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Plan of Correction
Each site manager will have a staff training by September 15, 2006 which will address the following objectives:
Ħ Creating a treatment plan which has measurable goals, and a review process of those goals from previous treatment plans
Each staff person will submit 3 charts for review by October 1, 2006. The manager will review to verify completion of treatment plan updates as well as for content of update. Content should include a review of client's goals and action steps from the treatment plan.
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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
Proposed support services were missing in three of four client records reviewed, # 1, 2, and 3.
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Plan of Correction
Each site manager will have a staff training by September 15, 2006 which will address the following objectives:
ĦA review of the support services in the area and how to note recommendations for those services in the treatment plans
Staff will submit 3 charts for review by the manager by October 1, 2006. The manager will review for inclusion and proper notation of support services.
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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
Treatment plan updates did not include a review of the client's progress on previously stated goals in four of four client records, # 1, 2, 3, and 4.
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Plan of Correction
Each site manager will have a staff training by September 15, 2006 which will address the following objectives:
Ħ Creating a treatment plan update which has a review of measurable goals, and action steps from previous treatment plans
Each staff person will submit 3 charts for review by October 1, 2006. The manager will review to verify completion of treatment plan updates as well as for content of update. Content should include a review of client's goals and action steps from the treatment plan.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Follow-up information was missing in two of two client records, # 4 and 5.
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Plan of Correction
Each site manager will have a staff training by September 15, 2006 which will address the following objective:
Correct procedures for documenting follow-up information
By October 1, 2006 each therapist will submit 3 charts with clients who required follow up. Each manager will review the charts and give feed back. Managers will continue to review charts on a monthly basis.
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