INITIAL COMMENTS
|
This report is the result of an on-site licensure renewal inspection conducted on March 27, 2007 through March 29, 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 24, 2007.
|
Plan of Correction
|
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.
|
Observations
Documentation was not presented for the fire alarm/smoke detector being set off during each fire drill.
|
Plan of Correction
1.The fire alarm is not activated with each fire drill as it is tied into the hospital fire alarm system. While the program participates in the hospital fire alarms we also conduct our own in order to remain compliant with the standard requiring it to be done monthly. Those additional fire drills are conducted using a whistle to simulate the fire alarm.
2.A letter will be written to BDAP requesting an exemption to this standard to allow for the current practice.
3.Completed by 5/31/07
4.Responsible Party: Director
|
711.81(b)(3)(iii) LICENSURE Personal History
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
The personal history was missing information regarding the client's family history and did not allow for any insight into the client's family of origin in two of four client records reviewed, #8, 9. The personal history was missing information regarding the client's sexual history. Specifically, the sexual history was missing the age of the client's first sexual experience and whether the client experienced any sexual dysfunction in four of four client records reviewed, #7, 8, 9 and 10.
|
Plan of Correction
1.Family history questions are not structured to prompt enough detail to satisfy the requirement
2.The Family History section will be revised to prompt for sufficient detail regarding the family of origin. It will also be expanded to include questions pertaining to client's first sexual experience and any sexual dysfunction related to their usage.Staff will be made aware of the new form through a scheduled inservice conducted by Director. Ongoing compliance will be determined through monthly chart audits.
3.Completed by 05/31/07
4.Responsible Party: Director
|
711.81(b)(6) LICENSURE Psychosocial Evaluation
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
The psychosocial evaluation was missing coping mechanisms in three of four client records reviewed, #8, 9 and 10. The psychosocial evaluation was missing clinical impressions regarding the client's attitude toward and ability to participate in the treatment process in two of four client records reviewed, #9 and 10.
|
Plan of Correction
1.Current question prompts the therapist for patients coping style but does not ask for the client's "coping mechanisms". Current question prompts the therapist for their impressions regarding the patient's attitude toward change but does not inquire as to their ability to participate in treatment. The Psychosocial Evaluation prompts the therapist for Support System Issues but does not ask specifically about "support systems".
2.The "Strengths/Assets" Section will be revised to include a question regarding "Coping Mechanisms". The Counselor impression section will be revised to include the "client's attitude toward and ability to participate in treatment". The question regarding support system issues will be revised to ask specifically about "client support systems".Staff will be made aware of the new form through a scheduled inservice conducted by Director. Ongoing compliance will be determined through monthly chart audits.
3.Completed by 06/29/07
4.Responsible Party: Director
|
711.82(c) LICENSURE Individualized Tx Plan
711.82. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Treatment plans were not individualized and based on client's specific needs in four of four client records reviewed, #7, 8, 9 and 10.
|
Plan of Correction
1.The current Treatment Plans lack sufficient detail to be deemed individualized based upon the client's needs.
2.The Treatment Plans will be revised to include more detailed treatment strategies based upon specific client needs. Staff will be made aware of the new form through a scheduled inservice conducted by Director.Ongoing compliance will be determined through monthly chart audits.
3.Completed by 05/31/07
4.Responsible Party: Director
|
711.82(c)(3) LICENSURE Support Service - Tx Plan
711.82. Treatment and rehabilitation services.
(c) 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.
|
Observations
Support services were missing in two of three client records reviewed, #7 and 8.
|
Plan of Correction
1.The therapist did not complete the proposed support services section.
2.This requirement will be review with all therapists in the monthly staff meeting. Staff will be made aware of the new form through a scheduled inservice conducted by Director. Monthly chart audits will be performed to monitor compliance.
3.Completed by 05/31/07
4.Responsible Party: Director
|
711.82(d) LICENSURE Tx Plan Updates
711.82. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
|
Observations
The treatment plan update was missing in one of one applicable client record reviewed, #9.
|
Plan of Correction
1.The therapist did not complete the treatment plan update in a timely fashion.
2.This requirement will be review with all therapists in the monthly staff meeting. Staff will be made aware of the new form through a scheduled inservice conducted by Director. Monthly chart audits will be performed to monitor compliance.
3.Completed by 05/18/07
4.Responsible Party: Director
|
711.83(a)(7) LICENSURE Follow-up Information
711.83. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
|
Observations
Follow-up information was missing in two of two client records reviewed, #9 and 10.
|
Plan of Correction
1.A combined termination and follow-up letter was utilized for clients who were unsuccessfully discharged from the program.
2.A separate "Follow-up" letter will be developed to be sent to clients who were Terminated or Therapeutically Discharged from the program. All clients who are successfully discharged will be called for follow-up.Staff will be made aware of the new process through a scheduled inservice conducted by Director.
3.Completed by 6/15/07
4.Responsible Party: Director
|
711.83(c)(2) LICENSURE Informed/Voluntary Consent
711.83. Client records.
(c) Confidentiality.
(2) 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:
|
Observations
The consent to release information form contained a parent/guardian signature line and included language to disclose and/or receive information in four of four client records reviewed, #7, 8, 9 and 10. These must be removed from consent to release forms.
|
Plan of Correction
1.Consent form is in need of revision.
2.Signature line for Parent/Guardian will be removed. Language which states "permission to disclose and/or receive information" will be changed to only " permission to disclose information"
3.Completed by 5/18/07
4.Responsible Party: Director
|
711.84(e) ELEMENT Follow-up Policy
711.84. Project management services.
(e) The project shall develop a written follow-up policy.
|
Observations
The follow-up policy stated that follow-up does not need to be completed for clients who leave against medical advice, who are terminated, or are therapeutically discharged. Follow-up must be attempted for all clients regardless of discharge status.
|
Plan of Correction
1.Current policy does not require follow up on patients who are unsuccessfully discharged, leave AMA or are therapeutically discharged.
2.The policy will be revised to include follow up on all discharged patients consistent with L1437.
3.Completed by
4.Responsible Party: Director
|
711.91(b)(3)(iii) LICENSURE Personal History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
The personal history was missing information regarding the client's family history and did not allow for any insight into the client's family of origin in six of six client records reviewed, #1, 2, 3, 4, 5 and 6. The personal history was missing information regarding the client's sexual history. Specifically, the sexual history was missing the age of the client's first sexual experience and whether the client experienced any sexual dysfunction in six of six client records reviewed, #1, 2, 3, 4, 5 and 6.
|
Plan of Correction
1.Family history questions are not structured to prompt enough detail to satisfy the requirement
2.The Family History section will be revised to prompt for sufficient detail regarding the family of origin. It will also be expanded to include questions pertaining to client's first sexual experience and any sexual dysfunction related to their usage. Staff will be made aware of the new forms/questions through a scheduled inservice conducted by Director.Ongoing compliance will be determined through monthly chart audits.
3.Completed by 05/31/07
4.Responsible Party: Director
|
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
The psychosocial evaluation was missing coping mechanisms in three of six client records reviewed, #1, 2 and 6. The psychosocial evaluation was missing clinical impressions regarding the client's attitude toward and ability to participate in the treatment process in one of six client records reviewed, #4.
The psychosocial evaluation was missing support systems in three of six client records reviewed, #3, 5 and 6.
|
Plan of Correction
1. Current question prompts the therapist for patients coping style but does not ask for the client's "coping mechanisms". Current question prompts the therapist for their impressions regarding the patient's attitude toward change but does not inquire as to their ability to participate in treatment. The Psychosocial Evaluation prompts the therapist for Support System Issues but does not ask specifically about "support systems".
2.The "Strengths/Assets" Section will be revised to include a question regarding "Coping Mechanisms". The Counselor impression section will be revised to include the "client's attitude toward and ability to participate in treatment". The question regarding support system issues will be revised to ask specifically about "client support systems". Staff will be made aware of the new forms/questions through a scheduled inservice conducted by Director.Ongoing compliance will be determined through monthly chart audits.
3.Completed by 06/29/07
4.Responsible Party: Director
|
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Treatment plans were not individualized and based on client specific needs in six of six client records reviewed, #1, 2, 3, 4, 5 and 6.
|
Plan of Correction
1.The current Treatment Plans lack sufficient detail to be deemed individualized based upon the client's needs.
2.The Treatment Plans will be revised to include more detailed treatment strategies based upon specific client needs. Staff will be made aware of the revised forms through a scheduled inservice conducted by Director.Ongoing compliance will be determined through monthly chart audits.
3.Completed by 05/31/07
4.Responsible Party: Director
|
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
|
Observations
Follow-up information was missing in two of three client records reviewed, #5 and 6.
|
Plan of Correction
1.A combined termination and follow-up letter was utilized for clients who were unsuccessfully discharged from the program.
2.A separate "Follow-up" letter will be developed to be sent to clients who were Terminated or Therapeutically discharged from the program. All clients who are successfully discharged will be called for follow-up.Staff will be made aware of the process through a scheduled inservice conducted by Director.
3.Completed by 6/15/07
4.Responsible Party: Director
|
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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:
|
Observations
The consent to release information form contained a parent/guardian signature line and included language to disclose and/or receive information in six of six client records reviewed, #1, 2, 3, 4, 5 and 6. These must be removed from the consents.
|
Plan of Correction
1.Consent form is in need of revision.
2.Signature line for Parent/Guardian will be removed. Language which states "permission to disclose and/or receive information" will be changed to only " permission to disclose information"
3.Completed by 5/18/07
4.Responsible Party: Director
|
711.94(e) LICENSURE Follow-up Policy
711.94. Project management services.
(e) The project shall develop a written client follow-up policy.
|
Observations
The follow-up policy stated that follow-up does not need to be completed for clients who leave against medical advice, who are terminated, or are therapeutically discharged. Follow-up must be attempted for all clients regardless of discharge status.
|
Plan of Correction
1.Current policy does not require follow up on patients who are unsuccessfully discharged, leave AMA or are therapeutically discharged.
2.The policy will be revised to include follow up on all discharged patients consistent with L1437.
3.Completed by 6/15/07
4.Responsible Party: Director
|