INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 2007 to May 17, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on June 19, 2007.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
The individual listed as the clinical supervisor exceeded the maximum permissible caseload for a full time clinical supervisor.
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Plan of Correction
The Clinical Supervisor was promoted to this position on April 1, 2007 and was interviewing potential candidates to replace the counselor position in which she vacated.
A full-time counselor was hired on June 11, 2007. The caseload has been re-assigned to the full-time counselor. At this time, the Clinical Supervisor has no caseload assigned to her. It shall be the responsibility of the Clinical Supervisor to insure all caseload ratios remain in compliance through weekly caseload monitoring.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
An individual training plan was not documented for employee # 2.
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Plan of Correction
Employee #2 did have an individual training plan completed, however a copy was missing from the employee's Personnel Record. SPHS Behavioral Health and SPHS Inc Human Resource Department are working collaboratively to address the documentation required in Personnel Records.
Project Director will submit a reminder memo to all Clinical Supervisors regarding the required documentation for employment and trainings for Personnel Records and submission to Human Resource Department. Human Resource Director and Project Director will insure ongoing compliance with this regulation through ongoing monitoring of Personnel Records. It shall be the responsibility of the Clinical Supervisor to insure all staff receive an individual training plan within 30 days of hire and submit copies to Human Resource Department.
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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.
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Observations
The client to counselor caseload exceeds the 35:1 limit at 36:1 for employee # 1.
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Plan of Correction
Employee #1 is the Clinical Supervisor. The Clinical Supervisor was promoted to this position on April 1, 2007 and was interviewing potential candidates to replace the counselor position in which she vacated.
A full-time counselor was hired on June 11, 2007. The caseload has been re-assigned to the full-time counselor. At this time, the Clinical Supervisor has no caseload assigned to her. It shall be the responsibility of the Clinical Supervisor to insure all caseload ratios remain in compliance through weekly caseload monitoring.
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The manual at the main administrative office contained redundant and contradictory policies and procedures. The general organization of the manual made the review difficult and increased the potential for misunderstanding the intent of various procedures. The manual should be organized to permit staff to readily access needed information and old and outdated information should be removed.
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Plan of Correction
SPHS Behavioral Health will correct all deficiencies and reorganize manuals to meet current manual standards.
It shall be the responsibility of the Project and Facility Director to insure the Policy and Procedure Manuals remain in compliance with standards through annual reviews of the manuals. |
709.24(a)(2) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Treatment models utilized by the project.
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Observations
The manual identified a number of different treatment models but did not define each one, choosing only to define the existential model and the criminal personality model. In order to determine that the project is providing client services consistent with the treatment models used, definitions of the specific agency application of each treatment model must be included.
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Plan of Correction
The missing definitions are an oversight on the part of the Facility Director.
Project and Facility Director will include definitions to the various treatment models used by SPHS Behavioral Health. It shall be the responsibility of the Clinical Supervisor to insure clinical documentation is consistent with the models as they are defined through clinical supervision and weekly chart reviews.
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709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
One transcript was not documented in employee record #2 which was also missing a job description and an individual training plan. Employee # 3 has no contract on file. Fire extinguisher and emergency procedures training was not documented for employees #1, 2 and 3.
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Plan of Correction
SPHS Behavioral Health and SPHS Inc Human Resource Department are working collaboratively to address the documentation required in Personnel Records. In addition, all missing documentation has been placed in the respective employee's Personnel Record.
It shall be the responsibility of the Clinical Supervisor to insure training plans and documentation of fire extinguisher and emergency procedures training is completed within specified time frames and submitted to Human Resource Department for placement in Personnel Record. Clinical Supervisor is also responsible for obtaining original transcripts of degrees and submitting to Human Resource Department.
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709.28(c)(3) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The purpose listed was unclear on consent to release information forms in the client records reviewed. The purpose must identify the reason for the release of information which must be logically consistent with the function of the entity specified.
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Plan of Correction
SPHS Behavioral Health did not provide a logically consistent purpose of the the release of information in regards to the function of the entity receiving information.
It shall be the responsibility of the Clinical Supervisor to review and train staff on clearly identifying the purpose of the informed consent and specify a logical and consistent reason for the release in regards to the function of a specific person or entity to insure only required and pertinent information is released. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through clinical supervision and ongoing weekly reviews.
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The facility failed to consistently include the client's progression of substance use/abuse as part of the lengths and patterns of use/abuse in client records # 1, 2, 4, 5, 6 and 7.
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Plan of Correction
SPHS Behavioral Health makes every attempt to obtain as much information regarding drug and alcohol histories on each client as possible.
It shall be the responsibility of the Clinical Supervisor to review all required components of the drug and alcohol history, specifically progression of use, length and patterns of use/abuse, with clinical staff. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews. |
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 facility failed; to provide for the collection of personal histories which adequately addressed the required areas in client records reviewed. Personal histories should collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated.
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Plan of Correction
SPHS Behavioral Health makes every attempt to obtain as much information regarding personal histories on each client as possible.
It shall be the responsibility of the Clinical Supervisor to review required components of the personal history with clinical staff. In addition, Clinical Supervisor will discuss efforts to obtain as much information as possible and document in the personal history with clinical staff. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance through clinical supervision and weekly chart reviews.
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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
Psychosocial evaluations did not contain complete information. Client record #5 was missing the psychosocial evaluation. Psychosocial evaluations were incomplete relative to negative factors and a composite picture.
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Plan of Correction
It shall be the responsibility of the Clinical Supervisor to review all required elements of the psychosocial evaluation as defined in regulation, including but not limited to the negative factors and to provide as much detail as possible in order to provide a composite picture. Examples will be provided indicated during the recent Department of Health Licensing visit as meeting this standard, to clinical staff. Clinical Supervisor will insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews.
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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 treatment goals listed on treatment plans in client records # 1, 4, and 5 were vague and failed to identifying measurable criteria to determine achievement of progress in relation to those goals.
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Plan of Correction
SPHS Behavioral Health makes every effort to develop treatment plans which are clear, include measurable criteria, and able to determine achievement of progress in relation to those goals.
It shall be the responsibility of the Clinical Supervisor to review all required elements of treatment plans and provide examples, indicated during the recent Department of Health Licensing visit as meeting this standard, to clinical staff. Clinical Supervisor will insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews.
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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
Group notes in the client records reviewed failed to include any information about group interactions and dynamics. When group sessions are conducted, individual notes need not be written for each client. One group note will suffice provided that it includes a comment relative to each individuals response or participation in the group session.
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Plan of Correction
SPHS Behavioral Health chooses to use individual group notes for each participant in group sessions. Group interactions or dynamics for each member need to be better documented.
It shall be the responsibility of the Clinical Supervisor to review and train staff on the group note documentation, including group member's interaction or group dynamics. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through clinical supervision and weekly chart reviews
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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.
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Observations
Follow up was not documented in accordance with agency policy in client record #6.
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Plan of Correction
The Follow-Up Policy in the manual was inconsistent with the practice of the programs.
Project and Facility Director will rewrite the Follow-Up Policy to accurately reflect that Follow-Up is conducted at 6 months post-treatment. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with the Follow-Up Policy through random supervision of discharged client charts.
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