INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 20, 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 May 18, 2007.
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Plan of Correction
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709.92(a) 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:
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Observations
The facility failed to consistently complete the psychosocial evaluation piror to the development of the comprehensive treatment plans. The comprehensive treatment plan is to be developed based on the information presented in the psychosocial evaluations. Client records number 3 and 6 have comprehensive plans documented prior to the completion of the psychosocial evaluations.
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Plan of Correction
Facility Director, James DeSanto, will retrain all staff on the agency protocols concerning the appropriate completion of psychosocial evaluations and treatment plans at the clinical staff meeting on 5/2/07. Attention will be focused on the time frames of completion for each document.
Facility Director will monitor weekly to ensure appropriate compliance beginning 5/8/07.
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