INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 13-14, 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 December 13, 2006.
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Plan of Correction
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709.26(e)(1) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(1) The employe's right to inspect his own records.
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Observations
The facility's policy relating to the employee's right to inspect their own record does not indicate a measurable time frame as to when the employee may expect to be able to review their own records. The policy states that they may submit in writing to the Executive Director and that they will receive a response within a "reasonable time".
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Plan of Correction
The Firetree policy has been reviewed and revised by the Firetree Policy Committee. Language has been added to include: "A Firetree employee may review their personnel file following approval of a written request to the program director or his/her designee."
"Time will be scheduled for the employee to review the record within ten working days of the submission of the written request". The facility director will ensure compliance. Timeframe: immediately.
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709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
The facility does not have policy or procedures in place that address the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Plan of Correction
The Firetree current policy and procedure manual (nos. 10-010 and 11-030) and employee handbook (section 1.11) contain policies concerning an employee's right to request the correction, etc. of information in the employee's personnel file in accordance with this regulation. The policy and procedure manual has, however, been reviewed and revised by the Firetree Policy Committee. Language has been added to include, "Employees have the right to request in writing to the program Director and/or his/her designee the correction or removal of inaccurate, irrelevant, outdated or incomplete information from their personnel records". Timeframe: immediately. The facility Director will ensure compliance. |
709.26(e)(3) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
The facility does not have policy or procedures in place that address the employee's right to request to submit rebuttal data or memoranda to his own records.
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Plan of Correction
The Firetree current policy and procedure manual (nos. 10-010 and 11-030) and employee handbook (section 1.11) contain policies concerning an employee's right to request the correction, etc. of information in the employee's personnel file in accordance with this regulation. The policy and procedure manual has, however, been reviewed and revised by the Firetree Policy Committee. Language has been added to include," Employees have the right to request in writing to the program director or his/her designee to submit rebuttal data or memoranda to his/her own personnel record". The facility director will ensure compliance. Timeframe: immediately. |
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 for releases to the criminal justice system stated that the consent cannot be revoked until (a specified date), in 2 out of 6 client records, specifically #2 and 6. A consent to release information form may be revoked by the client anytime unless the facility has documentation demonstrating that drug and alcohol treatment is a condition of probation or parole.
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Plan of Correction
The Clinical Director and the Charge Nurse will provide training to all clinical staff and nursing staff on the proper completion of the consent to release form to ensure that all forms are properly signed. Timeframe: completion of all staff training by Jan. 5th 2007. The corporate Compliance Officer shall continue on-going inspection of records in conjunction with on-going clinical supervision by the facility Clinical Director and Clinical Supervisor to ensure continued compliance. Additionally the Corporate Clinical Director will review and revise the consent form as needed upon his return from medical leave (mid-December). |
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 psychosocial evaluation (integrated summary) was primarily historical with little to no impressions in 6 out of 6 client records reviewed. Key elements of the psychosocial evaluation were simply listed at the end the the biopsychosocial history and offered very little ion the way of insight or opinion.
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Plan of Correction
The Clinical Director will instruct and train all clinical staff in the documenting clinical impressions and/or assessment as it relates to psychosocial evaluations and in collaboration with the Corporate Compliance Officer, miantain on-going monitoring of compliance.
Timeframe: 12/30/2006 |