INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20, 2006 through March 21, 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 April 27, 2006.
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Plan of Correction
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704.5(b) LICENSURE Clinical Supervisor
704.5. Qualifications for the positions of project director and facility director.
(b) If the facility does not have a clinical supervisor on staff, clinical responsibilities shall be addressed in one of the following ways:
(1) A facility director who has direct responsibility for clinical services shall meet the qualifications in at least one of the paragraphs of 704.7 (b) (relating to qualifications for the position of counselor).
(2) If the facility director does not meet counselor qualifications and the facility employs less than eight counselors, a lead counselor or part-time clinical supervisor shall be appointed.
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Observations
There are over 10.5 full-time equivalent counselors at Keenan House and no full-time clinical supervisor identified at the time of the licensing inspection.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
The policies and procedures for the staff development plan does not include the timeframes for the completion of the needs assessment, the overall training plan, the training feedback, and the annual evaluation of the training plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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 majority of the clinical records reviewed had several incomplete or blank sections.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Follow-up documentation was missing in records number 9 and 13.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |