INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 25, 2006 to April 27, 2006 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 May 19, 2006.
|
Plan of Correction
|
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
The Full-time equivalent (FTE) client to counselor ratio at the time of the licensing inspection was 51:1.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.21 (2) LICENSURE General req. for nonresidential facilities.
705.21. General requirements for nonresidential facilities.
The nonresidential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
|
Observations
No certificate of occupancy was available for review for the temporary meeting trailer being utilized by the program staff.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
|
Observations
There is no exhaust fan or window in the staff bathroom.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
In 13 out of 15 clinical charts reviewed, specifically #2, 4, 6, 9, 10, 11, 12, 13, 14, 15, 17, 18 and 19, the psychosocial evaluations were more historical than evaluative. In addition the assets/strengths, support systems, coping mechanisms and negative factors were not consistently addressed.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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.
|
Observations
The case consultations in 11 out of 17 clinical charts, specifically #2, 3, 4, 6, 8, 10, 12, 13, 14, 15 and 18, did not include a summary of the case consultation or the disposition.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
The aftercare plan in clinical chart #19 did not include specific goals or support services. In addition, the aftercare plan was missing from clinical chart #14.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
In 5 out of 7 clinical charts reviewed, specifically #12, 13, 14, 17 and 18, the discharge summary did not include the response to treatment. In addition, clinical chart #15 did not contain a discharge summary.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |