INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 27- 28, 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 July 24, 2007.
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Plan of Correction
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709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The facility failed to provide for a complete drug and alcohol history. The drug and history failed to include lengths and patterns of use in order to determine the client's progression of use in 2 of 2 client records reviewed, specifically #4 and 5. In addition, the client's perception of use failed to include how drugs and alcohol affected the various areas of his life.
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Plan of Correction
The Nursing Assessment will be discussed at the Forms Committee meeting on August 8, 2007 and will be developed by the Nursing Leadership Committee on August 29, 2007. The Forms Committee Chairperson will present the revised form to Senior Quality Leadership Committee on September 11, 2007 for review and approval. Approved form will be distributed by September 17, 2007. Trainings by Director of Nursing or designee will be provided to clinical staff with full implementation by October 1, 2007
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to provide for a psychosocial evaluation consistent with the standard. The psychosocial evaluation (evaluative summary) failed to include clinical opinions and impressions regarding problems/needs specific to the client, assets /strengths, negative factors that may effect treatment and overall conclusions in 2 of 2 client records reviewed, specifically #4 and 5. In addition, the evaluation primarily contained historical information with client reported statements and was not evaluative.
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Plan of Correction
Individual supervision will occur with all clinical and nursing staff on completion of evaluative summaries by 8/1/07. Supervisor will audit 10 percent of admissions for the next three months to monitor compliance and provide supervision as needed. |
709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. 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:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
The facility failed to provide for an individualized treatment plan. The short and long-term goals in the individual treatment plan were not individualized for each client in 2 of 2 client records reviewed, specifically #4 and 5. In addition, the actions steps for the short and long-term goals were identical.
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Plan of Correction
Clinical Supervisor will provide onsite training on treatment planning, by 8/20/07. Supervisor will audit and initial ten percent of treatment plans for each clinician for 3 months, effective immediately to monitor compliance and provide supervision as needed. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
The facility failed to provide for complete treatment plan updates. The treatment plan updates failed to include the client's progress as it relates to the goals identified on the individual treatment plan, but rather included generalized comments that were not specific to each client in 2 of 2 client records reviewed, specifically #4 and 5.
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Plan of Correction
Clinical Supervisor will provide onsite training on treatment planning, by 8/20/07. Supervisor will audit and initial ten percent of treatment plans for each clinician for 3 months, effective immediately to monitor compliance and provide supervision as needed. |
709.62(c)(3)(ii) LICENSURE D & A History
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The facility failed to provide for complete drug and alcohol histories. The drug and alcohol histories failed to include lengths and patterns pertaining to the progression of use in 5 of 5 client records reviewed, specifically #1, 2, 3, 4, 5 and 6. In addition, the client's perception of use simply listed the areas in his life affected by drugs and alcohol and failed to describe how the client's use affected these areas.
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Plan of Correction
The Nursing Assessment will be discussed at the Forms Committee meeting on August 8, 2007 and will be developed by the Nursing Leadership Committee on August 29, 2007. The Forms Committee Chairperson will present the revised form to Senior Quality Leadership Committee on September 11, 2007 for review and approval. Approved form will be distributed by September 17, 2007. Trainings by Director of Nursing or designee will be provided to clinical staff with full implementation by October 1, 2007. |
709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The facility failed to provide for a complete personal history. The personal history (nursing assessment) failed to include questions pertaining to the client's military and sexual history. In addition, the nursing assessment failed to include specific details regarding family relationships and employment history and how drugs and alcohol have affected those areas of life in 5 of 5 client records reviewed, specifically #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The addition of the military and sexual history to the Nursing Assessment will be discussed at the Forms Committee meeting on August 8, 2007 and will be developed by the Nursing Leadership Committee on August 29, 2007. The Forms Committee Chairperson will present the revised form to Senior Quality Leadership Committee on September 11, 2007 for review and approval. Approved form will be distributed by September 17, 2007. Trainings by Director of Nursing or designee will be provided to clinical staff with full implementation by October 1, 2007. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
The facility failed to include evaluative material in the psychosocial evaluation. The psychosocial evaluation (nursing assessment summary) failed to include opinions and impressions regarding the client in 5 of 5 client records reviewed, specifically #1, 2, 3, 4 and 5. The summary simply restated the client's demographics, drug of choice and appropriateness for the level of care.
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Plan of Correction
Individual supervision will occur with all clinical and nursing staff on completion of evaluative summaries by 8/1/07. Supervisor will audit 10 percent of admissions for the next three months to monitor compliance and provide supervision as needed. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The facility failed to provide for a complete drug and alcohol history. The drug and history failed to include lengths and patterns of use in order to determine the client's progression of use in 2 of 2 client records reviewed, specifically #2 and 3. In addition, the client's perception of use failed to include how drugs and alcohol affected the various areas of his life.
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Plan of Correction
The Nursing Assessment will be discussed at the Forms Committee meeting on August 8, 2007 and will be developed by the Nursing Leadership Committee on August 29, 2007. The Forms Committee Chairperson will present the revised form to Senior Quality Leadership Committee on September 11, 2007 for review and approval. Approved form will be distributed by September 17, 2007. Trainings by Director of Nursing or designee will be provided to clinical staff with full implementation by October 1, 2007. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The facility failed to provide for a complete personal history. The personal history failed to include details regarding family history and relationships, employment history and job skills and sexual history that includes significant relationships and abuse in 2 of 2 client records reviewed, specifically #2 and 3. In addition, the questions often contained one word answers with no further details documented.
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Plan of Correction
Individual supervision will occur with all clinical on completion of biopsychosocials and evaluative summaries by 8/20/07. Supervisor will audit 10 percent of admissions for the next three months to monitor compliance and provide supervision as needed. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to provide for a complete and evaluative psychosocial evaluation. The psychosocial evaluation (evaluative summary) failed to include clinical opinions and impressions regarding problems/needs specific to the client, assets /strengths, negative factors that may effect treatment and overall conclusions in 2 of 2 client records reviewed, specifically #2 and 3. In addition, the evaluation contained mostly historical information with client reported statements.
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Plan of Correction
Individual supervision will occur with all clinical and nursing staff on completion of evaluative summaries by 8/1/07. Supervisor will audit 10 percent of admissions for the next three months to monitor compliance and provide supervision as needed. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The facility failed to provide for an individualized treatment plan. The short and long-term goals in the individual treatment plan were not individualized for each client in 3 of 3 client records reviewed, specifically #3, 5 and 6. In addition, the actions steps for the short and long-term goals were identical.
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Plan of Correction
Clinical Supervisor will provide onsite training on treatment planning, by 8/20/07. Supervisor will audit and initial ten percent of treatment plans for each clinician for 3 months, effective immediately to monitor compliance and provide supervision as needed. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The facility failed to provide for complete treatment plan updates. The treatment plan updates failed to include the client's progress as it relates to the goals identified on the individual treatment plan, but rather included generalized comments that were not specific to each client in 3 of 3 client records reviewed, specifically #3, 5 and 6.
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Plan of Correction
Clinical Supervisor will provide onsite training on treatment planning, by 8/20/07. Supervisor will audit and initial ten percent of treatment plans for each clinician for 3 months, effective immediately to monitor compliance and provide supervision as needed. |