INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 1, 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 July 2, 2007.
|
Plan of Correction
|
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Emergency procedure training was not documented for employee #7. This training, as with the fire extinguisher training, may be included in the employee orientation, but must occur no later than seven days from the date of employment.
|
Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all Fire Safety requirements. A staff meeting was held on June 12, 2007 to review fire extinguisher training and emergency procedures. In addition, training on emergency procedures has been added to the employee orientation material. The Executive Director, William Knecht, will oversee this and make sure that all staff are trained |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Documentation was not presented for the fire alarm/smoke detector being set off during each fire drill. The facility is in a multi-purpose agency, if the facility does not feel it can pull the alarms without disturbing the other tenants, the director would need to provide documentation that the governing body of the facility has approved a means of alerting the staff of a fire alarm. In addition, the facility would need to send in a letter to the division explaining the process.
|
Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with fire safety requirements. We have a letter on file that was submitted to the licensing board explaining that we would set off a portable smoke detector in place of the buildings system. We have updated our file drill log to document that this device is being set off when fire drills are conducted. The Executive Director, William Knecht, will oversee this. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Psychosocial evaluations were not consistently completed in accordance with required timelines or did not address all required areas completely. (Client records #2, 4,5, 6). The evaluation should provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
|
Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all client record keeping requirements. Staff have been retrained on proper completion of psychosocial histories and evaluations. In addition, supervisors have been re-trained to monitor client psychosocial histories and evaluations to assure that they will be completed in their entirety and contain all of the required information, specifically including personal histories, detailed clinical impressions, assessment of strengths and weaknesses, support systems, and client coping mechanisms. The evaluations will provide a composite picture of the individual in relationship to collected historical information. The executive director, William Knecht, will oversee the clinical supervisors to assure that this is completed. |
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.
|
Observations
The content of treatment updates did not routinely address the progress on the stated goals of the treatment plans. The treatment plan update should include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan. Appropriate modifications should be made to treatment plans as indicated by the client's progress in treatment.( client records #1, 3).
|
Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all treatment planning requirements. We recognize that treatment plan updates need to consistently address client's progress towards meeting their treatment plan goals. Staff have been re-trained on proper completion of treatment plans and treatment plan updates. In addition, supervisors have been re-trained to monitor client treatment plans to assure that they will be completed within the proper timeframes and include all of the required information, specifically reviewing the progress on the stated goals of the treatment plans. The executive director, William Knecht, will oversee the clinical supervisors to assure that this is completed. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Follow up was not documented in client record #8.
|
Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all client record keeping requirements. Staff have been retrained on proper completion and documentation of follow-up. In addition, supervisors have been re-trained to monitor client follow-up to assure that it will be completed in a timely manner. The executive director, William Knecht, will oversee the clinical supervisors to assure that this is completed. |