INITIAL COMMENTS
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This is a report of the on-site licensure renewal inspection conducted on June 11 through 13, 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 July 6, 2007.
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Plan of Correction
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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
A consent to release information form for the funding source was not documented in four of five client records reviewed, # 2, 3, 4 and 5.
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Plan of Correction
Therapists have consistently completed an ROI for county funded clients; they have not consistently sompleted an ROI for MA funded clients resulting in this observation. Therapists were informed verbally and in writing by the clinical supervisor that they must complete the appropriate ROI on each client. The corporate compliance officer and clinical supervisor will review client records effective immediately to insure the ROI is completed on each client by their therapist. This activity will be monitored at least weekly by the clinical supervisor and discussed as needed during weekly supervision with the therapists. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Treatment plan updates were missing in one of three records reviewed, # 3 and late in one of three records reviewed, # 4.
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Plan of Correction
Therapists are aware of the regulatory guideline that a treatment plan update must be completed at least every 60 days; however, in the records reviewed, reviews were inconsistently completed as required. Staff were reminded of the regulatory requirements for this observation verbally and in writing by the clinical supervisor. The corporate compliance officer and clinical supervisor will monitor this area effective immediately. The clinical supervisor will review client records at least weekly to insure that therapists are completing all required 60 day reviews and that they are completed in a timely fashion. |
709.93(a)(2) LICENSURE Client records
709.93. 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:
(2) Medication records.
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Observations
Medication records were missing the frequency of use in five of five client records reviewed , # 1, 2, 3, 4 and 5.
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Plan of Correction
Staff are aware of the requirement to fill out the medication section of both the Bunney-Hamburg and bio-psycho-soc paperwork; however, they have not completely filled out these sections regarding "frequency of use" in client charts. Therapists were reminded verbally and in writing by the clinical supervisor of the requirement to complete the medication documentation in client charts, effective immediately. The corporate compliance officer and clinical supervisor will monitor this area; the clinical supervisor will review client charts at least weekly and discuss with therapists in weekly supervision sessions. |
709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
A case consultation was missing in one of two records reviewed, # 3.
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Plan of Correction
Staff are aware of the requirement for case consultation in client records, documentation was compliant with one exception resulting in this observation. The clinical supervisor has reminded staff of this requirement verbally and in writing; compliance with this requirement is expected immediately. The corporate compliance officer and clinical supervisor will monitor this area; the clinical supervisor will review client charts at least weekly for compliance with this item. Results will be discussed with therapists in weekly supervision. |