Observations
Based on an interview with the facility director, the project failed to provide a full-time clinical supervisor for every eight full-time counselors and counselor assistants.
The findings include:
The facility director was interviewed on August 19, 2011 at approximately 9:10 AM. Per regulation, a drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both. The project consists of six facilities. These six facilities are managed by one facility director. Three full-time clinical supervisors would be required for 29.35 full-time counselors. This regulation was cited during the January 31, 2011 licensing inspection. The facility director reported that the project is in the process of hiring a third clinical supervisor that will meet the qualifications for the position.
As of August 19, 2011, the facility director confirmed the project has 29.35 full-time counselors and only two full-time clinical supervisors.
|
Plan of Correction
Three Clinical Supervisors have had their duties re-assigned to reflect only drug and alcohol supervision duties. An additional supervisor was hired effective October 1, 2011 to take on the non-drug and alcohol assignments of the respective supervisors listed above.
It shall be the resposibility of the Project and Facility Director to insure the appropriate number of Clinical Supervisors to staff ratio is met through monthly reviews of staffing pattern guidelines and ratios. |
Observations
Based on a review of client records, the facility failed to document treatment plan review and updates within sixty days, as per policy and regulation, in four of four outpatient client records.
The findings include:
Nine outpatient client records were reviewed on August 17, 2011. Four client records required treatment plan review and updates. One client record was not yet due for a treatment plan review and update. Four client records were from a timeframe outside of the follow-up inspection. Per the facility policy and regulation, treatment plan review and updates are required to be completed every sixty days. The facility failed to document treatment plan review and updates every sixty days, in client records # 1, 2, 3 and 4.
Client # 1 was admitted into treatment on April 1, 2011 and discharged on July 29, 2011. The individual treatment plan was completed on April 19, 2011. A treatment plan review and update was due to be completed no later than June 19, 2011. There was no documentation of any treatment plan review and updates in client record # 1, at the time of the review on August 17, 2011.
Client # 2 was admitted into treatment on February 2, 2011. The individual treatment plan was completed on March 1, 2011. The first treatment plan review and update was completed on April 29, 2011. The second treatment plan review and update was due to be completed no later than June 29, 2011. The second treatment plan review and update was not documented until July 22, 2011.
Client # 3 was admitted into treatment on April 6, 2011. An individual treatment plan was due to be completed no later than May 6, 2011. A treatment plan review and update was due to be completed no later than July 6, 2011. There was no documentation of any treatment plan review and updates in client record # 3, at the time of the review on August 17, 2011.
Client # 4 was admitted into treatment on May 3, 2011. An individual treatment plan was completed on May 27, 2011. A treatment plan review and update was due to be completed no later than July 27, 2011. There was no documentation of any treatment plan review and updates in client record # 4, at the time of the review on August 17, 2011.
The clinical supervisor was interviewed throughout the follow-up inspection and confirmed that treatment plan updates were not completed every 60 days, as required.
|
Plan of Correction
Treatment Plans and reviews were completed on the 4 clients reviewed during this inspection visit.
The Clinical Supervisor will review the requirement and appropriate completion of treatment plan updates and reviews with the clinical staff.
It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through weekly chart supervision. |