INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 29- 31, 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 June 25, 2007.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
3 of 15 staff members, specifically #6, 8 and 9, failed to receive a minimum of 6 hours of HIV/AIDS training within the first year of employment.
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Plan of Correction
A HIV/AIDS Training will be scheduled immediately and all other new employees will have HIV/AIDS Training within the required time frame. The Clinical Supervisor and Program Director will ensure that all employees will have the proper training within the required time frame. |
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 drug and alcohol histories in 2 of 10 client records reviewed, specifically #9 and 13, were not updated by the counselor after the client was re-admitted.
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Plan of Correction
The Clinical Supervisor will ensure that all readmissions to the facility will have updated drug and or alcohol history. The Program Director will do sporadic checks to ensure this is being done. |
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 in 2 of 10 client records reviewed, specifically #9 and 13, were not updated by the counselor after the client was re-admitted. In addition, the personal histories failed to provide the detailed information required regarding family, education and employment in client records #1, 2, 8, 12 and 14.
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Plan of Correction
The Clinical Supervisor will hold trainings to ensure that all readmissions to the facility will be updated and have detailed information regarding family, education and employment. The Program Director will do sporadic checks to ensure this is completed. |
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 evaluation was historical rather than evaluative and failed to include client specific assets/strengths, support systems, coping mechanisms and negative factors in 10 of 10 client records reviewed, specifically # 1, 2, 6, 8, 9, 12, 13, 14, 15 and 16.
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Plan of Correction
The Clinical Supervisor will conduct trainings and ensure that all psychosocial evaluations will be evaluative and will include assets/stregths, support systems, coping mechanisms, and negative factors are included in the psychosocial evaluation. The Program Director will do sporadic checks to ensure this is being completed. |
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
Aftercare plans were missing in 2 of 2 client records reviewed, specifically # 12 and 13.
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Plan of Correction
: The Clinical Supervisor will hold trainings to ensure the aftercare plans are being completed and placed in the client records. The Clinical Supervisor and Program Director will do chart audits to ensure that the aftercare plans are being completed and placed in the client records.
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