INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on March 21, 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 April 20, 2007.
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Plan of Correction
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
A notification of termination was missing in one of one client record reviewed, #2.
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Plan of Correction
A notice of termination was not completed due to this client ending the school year at our facility. Some of the programs are on a school year calendar from September to June, which is made explicit at time of entry. In addition, a client may return to their home school midway through the year, which would end their treatment at our program. If a client was to be prematurely discharged from the program a notice would be sent ending services. The executive director will train, supervise and ensure that staff are aware of proper notification of termination by 5/15/07. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
An opportunity for the client to request reconsideration of a decision terminating treatment was missing in one of one client record reviewed, #2.
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Plan of Correction
All clients are given several opportunities to remain in treatment except when a client is discharged at the end of a school year. Some of the programs are on a school year calendar from September to June, which is made explicit at time of entry. In addition, a client may return to their home school midway through the year, which would end their treatment at our program. This process is inclusive and is typically the goal for all clients. If a client is in need of continued treatment every effort is made to refer them to a community resource for continuation of treatment. The executive director will revisit with staff the importance of continuation of care and documenting this appropriately by 6/1/07. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. 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 personal history was missing information regarding the client's family history, family of origin and sexual history in two of two client records reviewed, #1 and 2.
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Plan of Correction
Personal histories were missing specific information regarding sexual history and family origin. The program will be in full compliance by 7/15/07 by revising the personal history report to include more specific questions relating to family and sexual history. The executive director will ensure, supervise and train staff to complete the revised paperwork and monitor the completeness of histories. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Treatment plans were not individualized in two of two client records reviewed, #1 and 2.
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Plan of Correction
Treatment plans were missing individuality because of how the reports describe objectives and goals generally and lack specificity. When compared to each other they can look similar. By 7/15/07, the program will be in full compliance by changing the documentation to include individualized plans. Clients will be engaged and asked to write down areas of treatment needed along with the counselor. This will ensure individuality of reports. The executive director will ensure, supervise and train staff to complete the revised paperwork and monitor the change in treatment plans. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. 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 personal history was missing information regarding the client's family history, family of origin and sexual history in two of two client records reviewed, #3 and 4.
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Plan of Correction
Personal histories were missing specific information regarding sexual history and family origin. The program will be in full compliance by 7/15/07 by revising the personal history report to include more specific questions relating to family and sexual history. The executive director will ensure, supervise and train staff to complete the revised paperwork and monitor the completeness of histories. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Treatment plans were not individualized in two of two client records reviewed, #3 and 4.
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Plan of Correction
Treatment plans were missing individuality because of how the reports describe objectives and goals generally and lack specificity. When compared to each other they can look similar. By 7/15/07, the program will be in full compliance by changing the documentation to include individualized plans. Clients will be engaged and asked to write down areas of treatment needed along with the counselor. This will ensure individuality of reports. The executive director will ensure, supervise and train staff to complete the revised paperwork and monitor the change in treatment plans. |