INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 14, 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 April 9, 2007.
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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
The facility did not document monthly supervisory meetings for the clinical supervisor.
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Plan of Correction
Program Director will schedule and document monthly meetings with the clinical supervisor. This will be monitored by the Executive Director. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
The facility did not set off fire alarm or smoke detector during fire drills.
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Plan of Correction
Program Director will set off alarms and smoke detectors and provide documentation of fire drills. This action will be monitored by the Executive Director. |
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 annual report did not include income and expenses.
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Plan of Correction
The Chief Financial Officer will include income and expenses in the annual report. This action will be monitored by the executive director. |
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
A performance report summarizing the progress towards meeting previous goals and objectives was not completed.
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Plan of Correction
The executive director will complete a performance report summarizing the progress towards the goals and objectives. This action will be monitored by the chief executive officer. |
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 annual audit was not completed.
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Plan of Correction
The chief financial officer will complete the audit. This action will be monitored by the executive director. |
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
Consent to release information forms were not completed for information sent to the laboratory in six of six records reviewed, # 1, 2, 3, 4, 5 and 6.
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Plan of Correction
The Program Director will institute a consent to release information sent to the laboratory and provide training in completing the form. This action will be monitored by the executive director. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations did not address support systems and negative factors that may inhibit treatment in five of six records reviewed, # 1, 2, 3, 5 and 6.
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Plan of Correction
The clinical supervisor will train staff to address support systems and negative factors on the Psychosocial evaluations. This action will be monitored by the program director. |
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
Support services were not include in five of six records reviewed, # 1, 3, 4, 5 and 6.
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Plan of Correction
The clinical supervisor will provide training to the clinicians on treatment plans to include support systems. This action will be monitored by the program director. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The treatment plan updates did not include a review of progress on previously stated goals in four of six records reviewed, # 2, 4, 5 and 6.
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Plan of Correction
The clinical supervisor will provide a training for the clinicians on treatment plan updates. This training will include documenting the progress of previously stated goals. The program director will monitor this action. |
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.
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Observations
The aftercare plans did not include time frames for goals and a re-entry process in four of six records reviewed, # 9, 10, 11 and 12.
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Plan of Correction
The clinical supervisor will facilitate a training on aftercare plans with the clinicians. This training will address the need to include time frames for goals and the re-entry process. This action will be monitored by the program director. |