INITIAL COMMENTS
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This is a report of the on-site licensure renewal inspection conducted on October 16 through 20, 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 16, 2006.
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Plan of Correction
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Performance evaluations were not completed in two of five employee records reviewed, #1 and 3.
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Plan of Correction
The Program Director and the Clinical Supervisor will complete the two deliquent performance evaluations within the next three weeks. The evaluation will then be placed in the staff personnel file. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The type and frequency of services to be provided were missing in two of eight client records reviewed, # 1 and 2. The frequency was missing in one record, #3.
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Plan of Correction
The clinical supervisor will meet with the clinical staff to review the required eliments that make up a client treatment plan. An emphasis will be placed on documenting the the type of services that client will participate in while in treatment as well as their frequency of participation, ie; once a week, group 2x's a week etc.
This has been completed and documented. |