INITIAL COMMENTS
|
This is a report of the on-site licensure renewal inspection conducted on March 14 through March 30, 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 April 27, 2006.
|
Plan of Correction
|
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.
|
Observations
The overall training plan was missing.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Individual training plans were late in employee records #2, #4 and #6.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
|
Observations
The facility policy and procedure manual was not organized and was repetitive.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Support systems were not evaluated in seven of eight client records. Negative factors were missing in four of eight client records.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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:
|
Observations
Treatment plans were not completed according to agency policy in three of eight client records.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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.
|
Observations
Support services were missing on seven of eight treatment plans.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Case consultation notes were missing in four of seven records.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Aftercare plans lacked goals with timeframes in three of five client records.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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.
|
Observations
Follow-up information was missing in three of eight client records.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |