INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on June 18, 2007 through June 22, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on July 16, 2007.
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Plan of Correction
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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
Treatment plan updates failed to include an assessment of the client's progress in relationship to the stated goals of the treatment plan in two of four client records reviewed, #3 and 4.
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Plan of Correction
Counselors were not trained to note in the treatment plan when a goal was completed. New Clinical Director will train counselors to record in the treatment plan when a goal is completed. Clinical Director will monitor counselor compliance with training. |
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
Treatment plan updates failed to include an assessment of the client's progress in relationship to the stated goals of the treatment plan in three of three client records reviewed, #1, 3 and 4.
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Plan of Correction
Counselors were not trained to note in the treatment plan when a goal was completed. New Clinical Director will train counselors to record in the treatment plan when a goal is completed. Clinical Director will monitor counselor compliance with training. |
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
The facility failed to document follow-up information in two of two client records reviewed, #3 and 4.
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Plan of Correction
Former Clinical Director did not maintain an accurate master list of discharge clients. New Clinical Director will maintain an accurate master list of discharge clients. Executive Director will monitor Clinical Director's completion of this list on a monthly basis in Quality Management meeting. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
The facility failed to adhere to the licensed authorized capacity for the Outpatient Drug-Free activity. The authorized capacity is 125. The client census during the licensing inspection was at 131.
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Plan of Correction
New Clinical Director was not aware of the Outpatient capacity of the agency. Executive Director will train Clinical Director on capacity limits for all programs. Executive Director will request an increase in the Outpatient capacity. |