INITIAL COMMENTS
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This is a report of the on-site licensure renewal inspection conducted on January 9, 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 February 2, 2007.
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Plan of Correction
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Medical histories were missing in two of six records, #4 and 5.
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Plan of Correction
The histories were missing due to some misunderstanding on the part of staff. They were sending it out to be completed by the physician rather than completing it themselves upon admission. The staff were educated upon this error 1/9/2007 and the issue will be resolved with future admissions. The staff will complete the form themselves rather than send it out. The office secretary will review all current charts to confirm they contain a history. If it is missing the counselor will complete it with the patient in their next individual session. This will be completed within the next 7 working days. |
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
A treatment plan update was missing in one of one client record, #6.
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Plan of Correction
This was addressed with the staff member 1/9/07. This will be further reinforced by the director of outpatient services in a counselor inservice to be held 1/19/07. The director of OP services will monitor throughout chart audits for consistency. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
The record of services should be one document listing the service provided, date, provider and duration of the service. The record of services in four of seven records, # 4, 5, 6 and 7, was two documents and one did not state who provided the service or what type of service was provided.
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Plan of Correction
Staff members were keeping separate records of service for group and individual sessions. Staff were instructed 1/9/07 to consolidate both services onto one sheet and were reminded to state whether it was group or individual and to identify who provided the services. This has been in effect since 1/9/07. This will be reinforced further at a counselor inservice 1/19/07 |