INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 5 through 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 March 13, 2007.
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Plan of Correction
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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 histories were missing information regarding family, employment, education, recreation and sexual history in two of three client records reviewed, #5 and 7. In addition, there was no documentation indicating how the clients' drug and alcohol use effected these areas of their lives.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations were historical rather than evaluative in two of three client records reviewed, # 5 and 7. The client's problems/needs, support systems and coping mechanisms were not addressed.
This is a repeat deficiency.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
The treatment plan updates did not address the action steps completed by the client, nor the client's progress or lack thereof in the past 60 days in two of three client records reviewed, # 7 and 10.
This is a repeat deficiency for the same reasons noted above during licensing inspections in 2005 and 2006.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Client's did not receive the required individual counseling (at least twice weekly for 6 weeks, 4 weeks and 8 weeks respectively) in three of three client records reviewed, # 5, 7 and 10.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.83(a)(9) LICENSURE Client records
709.83. 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) Progress notes.
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Observations
The progress notes did not accurately reflect individual and group counseling sessions in three of three client records reviewed, # 5, 7 and 10. Although the progress notes attempted to related to specific action steps in the treatment plan, there was no continuity between the the steps addressed and sessions.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
The notice of termination was missing in four of four client records reviewed, #10, 12, 13 and 15.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Clients' were not given the opportunity to request reconsideration of the decision to terminate treatment in four of four client records reviewed, #10, 12, 13 and 15.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 histories were missing information regarding family, employment, education, recreation and sexual history in seven of seventeen client records reviewed, # 4, 5, 6, 7, 12, 16 and 18. In addition, there was no documentation indicating how the clients' drug and alcohol use effected these areas of their lives.
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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.
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Observations
The psychosocial evaluations were historical rather than evaluative in seven of seventeen client records reviewed, # 2, 4, 5, 8, 15, 16 and 18, . Client's problems/needs, support systems and coping mechanisms were not addressed.
This is a repeat deficiency from the licensing inspection in 2006.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The individual treatment plans included similar short and long-term goals in five of fourteen client records reviewed, # 2, 4, 5, 16 and 18. In addition, the action steps for the various goals were often generalized to the point that they could have been goals themselves.
This is a repeat deficiency from the licensing inspection in 2006.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Proposed support services were not properly identified on the individual treatment plans in five of fourteen client records reviewed, # 2, 4, 7, 11 and 18. The only noted support services were AA/NA groups.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Treatment plan updates did not address the action steps completed by the client, nor the client's progress or lack thereof in the past 60 days in nine of fourteen client records reviewed, # 1, 2, 3, 5, 11, 13, 16 and 17.
This is a repeat deficiency from the licensing inspections in 2005 and 2006.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
The progress notes did not accurately reflect individual and group counseling sessions in six of sixteen client records reviewed, # 5, 10, 11, 12, 13 and 18, . Although the progress notes attempted to related to specific action steps in the treatment plan, there was no continuity between the the steps addressed and sessions themselves.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
A letter sent to an employer by a clinician violated the parameters of 255. 5(a)(6) in that information disclosed to the employer was more than just whether or not the client was in treatment in one of fifteen client records reviewed, # 1.
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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.
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Observations
The aftercare plan did not include specific goals with specific timeframes in one of two client records reviewed, #15. The aftercare plan for a successfully discharged client was missing in one of two client records reviewed, #10.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |