INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16, 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 November 7, 2006.
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Plan of Correction
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Physical exams contained only a summary of results in four of ten records reviewed, # 2, 4, 7, and 11.
Physical exams were missing vital signs and general appearance in two of ten records reviewed, # 3 and 4.
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Plan of Correction
Physical examinations will be complete to include vital signs and general appearance. We have contracted with a physician and Division Director has reviewed the physical exam form with physician. Case Manager and Division Director will review completed physical examination forms for compliance. Division Director will review this regulation with entire staff at staff meeting on 11/15/06.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations did not include an evaluation of support systems in three of five records reviewed, # 1, 2 and 5. Psychosocial evaluations did not include coping/defense mechanisms in three of five records reviewed, # 1, 3 and 4.
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Plan of Correction
Psychosocial evaluations will include an evaluation of support systems as well as coping/defense mechanisms. Division Director and Program Supervisor will provide an in-service training to clinical staff on 11/15/06. Division Director and Program Supervisor will monitor charts for compliance.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The program did not conduct group therapy sessions as stated on the treatment plans (one time a week) in three of five records reviewed, # 2, 3 and 4.
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Plan of Correction
Group Therapy sessions will be conducted 1x/week as stated in the treatment plan. This will be monitored by Program Supervisor and Division Director on a weekly basis by reviewing record of service and group note in clinical chart. Clinical meeting conducted on 10/20/06 to inform clinical staff of procedure and documentation of group therapy sessions.
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