INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 30- February 1, 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 March 6, 2007.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
The staffing compliance plan was not approved by the Pinnacle governing body. This statement must be approved by the governing body.
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Plan of Correction
Board meeting will address this issue on 4/24/07. |
709.22(b) LICENSURE Governing Body
709.22. Governing body.
(b) If a project is publicly funded, not more than one staff member of the project may sit on the governing body at a designated time.
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Observations
No documentation was on file to verify who sits on the governing body for Pinnacle Treatment Centers. Documentation must be available to demonstrate compliance with this regulation.
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Plan of Correction
Board Meeting will adress this issue on 4/24/07. |
709.22(c)(2) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(2) Qualifications for membership.
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Observations
No documentation was presented to specify qualifications for Board membership.
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Plan of Correction
Board Meeting will address this issue on 4/24/07. |
709.22(c)(3) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(3) Criteria for continued membership.
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Observations
No criteria for continuing Board membership were specified.
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Plan of Correction
Board Meeting will address this issue on 4/24/07. |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
No method of selection for the Project Director was specified in the materials presented.
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Plan of Correction
Board Meeting will address this issue on 4/24/07. |
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.
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Observations
The manual did not include approval by the Pinnacle governing body. The manual was not complete in regard to clearly identifying the relationship of Pinnacle Treatment Center to Alliance Medical.
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Plan of Correction
Board Meeting will address this issue on 4/24/07. |
709.23(b) 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:
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Observations
No documentation was presented to verify that the Project Director and the Pinnacle Board collaborated in the formulation of the goals and objectives, written reports of project operations or a performance report addressing progress on goals and objectives.
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Plan of Correction
Board Meeting will address this issue on 4/24/07. |
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
No goals and objectives were documented for the current fiscal year.
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Plan of Correction
The Board that was in place for 2006 has been disbanded. |
709.23(b)(3) 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:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
No performance report summarizing progress toward meeting goals and objectives for 2006 was presented during the inspection.
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Plan of Correction
The Board that was in place for 2006 has been disbanded. Goals for 2007 will be approved via the next Board Meeting. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories should collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated. Files reviewed did not provide complete information on family dynamics, work histories and educational histories.
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Plan of Correction
The Facility Director and Clinical Supervisor will provide training in further development of the personal histories. Ongoing training and compliance will be monitored by the Clinical Supervisor. In addition, the form used for these histories will be reviewed for possible changes/additions. |