INITIAL COMMENTS
|
This report is the result of an on-site licensure renewal inspection conducted on July 24, 2007 through July 26, 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 August 20, 2007.
|
Plan of Correction
|
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
|
Observations
The facility failed to document aftercare plans that included the client's future goals with time frames. Aftercare goals were not based on each individuals needs and did not include time frames in three of three client records reviewed, #5, 8 and 13.
|
Plan of Correction
1. Aftercare form is re-designed to including the following:
a. Goals
b. Methods
c. Identified Support Services
d. Estimated time frames for completion.
The form is signed and dated by the patient and counselor.
Responsible person: Clinical Supervisor 08-10-2007
2. Inform Clinical Staff of revised requirements during clinical team meeting of 8-20-2007.
Responsible Person: Clinical Supervisor 08-20-07
3. Modify policy on Follow-up and aftercare plan to reflect revised form and requirements.
Responsible Person: Program Director
08-20-2007
4. Review discharged patient records on clinical staff to monitor content of form during individual supervision monthly. 08-20-2007 through 11-30-2007 or longer if needed to ensure compliance.
5. Include in September 2007 Staff Meeting Minutes to ensure communication to all staff members.
Responsible Person: Program Director
9-12-2007
|
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
|
Observations
The facility failed to document follow-up information within the time frame identified in their policy and procedure in four of five client records reviewed, #5, 6, 7 and 13.
|
Plan of Correction
1. Review follow-up/aftercare policy to state that follow-up is conducted by the end of the month following discharge of the patient to be consistent with the current practice being used to complete follow-up in the facility.
Responsible Person: Program Director
Date: 08/20/2007
Monitor: Quarterly
2. Include in September 2007 staff meeting minutes to ensure communication of change to all staff.
Responsible Person: Program Director
Date: 08/20/2007
|