INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 14 through 15, 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 12, 2006.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Monthly supervision was not documented for the three new clinical supervisors.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
The fire drill log did not indicate that alternate exits were used during fire drills.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The evaluations did not include assets/strengths in six of twenty records reviewed, #1, 3, 4, 5, 6, 12 and 23. Psychosocial evaluations did not include an evaluation of support systems in twelve of twenty records reviewed, # 2, 3, 4, 7, 8, 9, 11, 12, 15, 17, 18 and 19. The evaluations did not include coping/defense mechanisms in seven of twenty records reviewed, # 1, 3, 5, 7, 8, 14 and 19.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Treatment plan updates did not provide a review of progress on previously stated goals in seven of twenty records reviewed, # 1, 2, 10, 21, 22, 23 and 24.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
An aftercare plan was missing in one of one record reviewed, # 29.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Follow up information was not documented as per policy in eight of twelve records, #21, 22, 24, 25, 27, 28, 30 and 31.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
This section of the consent form was not completed as per agency policy in five of twenty records reviewed, #1, 2, 6, 7 and 16.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |