INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 30 & 31, 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 25, 2007.
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The client to counselor ratio is 37 to 1. The counselor assistant that is in the direct observation supervision period does not qualify to carry a caseload and could not be counted.
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Plan of Correction
RHJ is out of compliance due to a new hire who is in the observation supervision period, therefore he could not be counted. Counselor observation will be complete and RHJ will be in compliance on August 15, 2007. RHJ will cease admissions to decrease this ratio and upon sucessful completion assessment, and determination of couselor assistants ability to carry a caseload RHJ will begin admissions again. The project/facility director is responsible to ensure that this plan for correction is implimented. RHJ should obtain compliance by 8/15/2007 as determined by Counselor assistants current progress in training. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
The facility failed to make the annual report available to the general public.
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Plan of Correction
RHJ is out of compliance due to improper advertising to make that annual report available to the public. Next year I Kerri Csikesz will be responsible to ensure that proper advertising has occured to maintain compliance. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
The facility failed to complete an annual audit for October 2005 to September 2006. A financial statement was presented in lieu of an audit.
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Plan of Correction
RHJ Mis not in compliance due to the advice of our accountant who recommended that we not complete a full audit. The organization will complete a full audit of all of the financial activity within the next six months. |
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 facility failed to address supportive services on the treatment plans in four out of eight client records reviewed. Client records # 2, 3, 4, & 7.
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Plan of Correction
RHJ is out of compliance due to counselors not being mindful to complete the supportive services section of the treatment plan. Upon auditing any deficiencies will be noted and trainings will be held to maintain compliance in this area. I the project/facility will hold a meeting/training with the counselors to remind them of the importance of utilizing the supportive services section of the treatment plan. This will be implimented immediately and RHJ will be in compliance by 8/1/2007. |