INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20, 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 October 20, 2006.
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Plan of Correction
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704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
The client to counselor ratio is 10:1. The maximum ratio permitted is 8:1.
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Plan of Correction
The client ratio is 10:1. As a halfway house we have women going to school, volunteering,working and rarely have all 18 client in the house at one time. I wrote for a varience a few years ago and received a call from Ms. Warner stating since I was a halfway house and a member of the Halfway House Association that this was not an issue for us.
We have been down a counselor and the clinical supervisor and director have been carring the caseload.
The director will again request a varience for the client to counselor ratio.
HH has 18 approved beds and in the event that the varience is not approved the director and or the clinical supervisor will carry the additional caseload. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
A fire drill is missing for April 2006. Fire drills are to be conducted monthly.
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Plan of Correction
The CT scheduled fire drill for the month of April was not conducted.
Beginning in October on the 15th of each month the house manager, the CT's supervisor, will check the safety manual to assure that the drill has been completed for that month. If it has not been completed a drill will be run that day according to the hour that was scheduled for that month.
The Director will check to assure that this is completed as scheduled. |
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
Chart #1 did not have a release of information signed for a release of information to CCBH (a third party payer). A consent to release information was not executed for a release of information made during a dental referral. The releases of information were acknowledged by clinical documentation notes included in the chart.
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Plan of Correction
The life skills technician did not have signed releases in two charts before referral sources were contacted.
The clinical supervisor/director has had a training meeting with the life skills tech. As Oct 1, 2006 the life skills technician will write releases for the referral sources before contacting the referral sources.
The CS/ED will check the charts on a monthly basis to assure that this does not happen again. |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
The follow up policy failed to address time frames, the staff responsible for conducting the follow up attempt, and the procedure for documenting the attempt.
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Plan of Correction
The long term tracking policy was not explicit enough to provide the directions necessary to conduct the process.
The process was implimented according to the guidelines of the long term tracking form in the year 2000. Documentation was available however exact directions were not written in the policy.The director has revised the policy as follows.
Rev. 10/16
LONGITUDINAL TRACKING POLICY
POLICY:
Each client who enters Highland House will be followed for one year after discharge according to the following schedule. The Counselor will make the first contact to each client within (72) hours in the event the client did not graduate from the program. The Counselor will contact each client that has completed the program within 7 days after their scheduled aftercare appointment to document that they kept their appointment. The Clinical Technician will contact each client in (30) days after discharge, (60) days (90) days, (6) months, and (1) year. The purpose of this follow up is to (1) maintain an individual record of client progress, (2) to document effectiveness of the program with the purpose of improving services and (3) to provide statistical documentation for managed care/referral sources. It will be the responsibility of the Director to oversee the implementation of this policy. The executive secretary will maintain the statistical records.
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