INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 31, 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 October 5, 2006.
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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 project had more than eight full time counselors (10) and lacked a full time clinical supervisor. The current clinical supervisor also serves as the facility director.
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Plan of Correction
Our project is in full compliance with this standard as of today 9/20/06. We mistakenly identified our full time clinical supervisor as also being the facility director on the "Staffing Requirements Facility Summary Report." This mistake was discovered during the on-site licensure renewal inspection. In actuality, our Project Director is also the Facility Director and our Clinical Supervisor is indeed full time. In the future we will correctly identify these positions on the report. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Employee # 7 did not receive 12 of 12 required training hours for the 2005 training year.
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Plan of Correction
Our project will be in full compliance with this standard by 6/30/07, which is the end of our current training year. By that date employee #7 will have received 12 training hours as is required by the standard. Due to a misunderstanding, this employee failed to follow through with the required training. This employee will seek out and attend trainings throughout the year which will address the areas set forth by the standard. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
The times of the facility's fire drills were not varied.
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Plan of Correction
Our project is in full compliance with this standard as of today 9/20/06. During the 9/14/06 staff meeting, this standard was reviewed with all staff members. The need to vary the times of fire drills was specifically reviewed. Last evening, 9/19/06, a fire drill was conducted at a different time than the other fire drills had been. Additionally, a reminder sheet regarding the necessary parts to a fire drill has been posted along with the fire drill log to help with future fire drills. |
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
Work performance evaluations were not completed in two of two personnel records reviewed, #1 and 7.
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Plan of Correction
Our facility will be in full compliance with this standard by 9/30/06. Employees #1 and #7, as co-owners of the business, complete work performance evaluations on one another and had failed to do so in a timely manner, the last ones being completed in June of 2005. Both of these work performance evaluations will be completed by 9/30/06 and will be filed in their personnel files. |
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
Support services were not documented in four of six client records reviewed, #1, 4, 5 and 6.
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Plan of Correction
Our facility will be in full compliance with this standard by 10/31/06. This standard and our agency policy relative to this standard will be reviewed with all counselors at our next staff meeting on 10/12/06. The proper documentation of proposed type of support services will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. |
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 were missing in two of six records reviewed, #1 and 4.
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Plan of Correction
Our facility will be in full compliance with this standard by 10/31/06. This standard and our agency policy relative to this standard will be reviewed with all counselors at our next staff meeting on 10/12/06. The proper completion and timetable for completion of the treatment plan update will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Medication records were not documented in two of six records reviewed.
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Plan of Correction
Our facility will be in full compliance with this standard by 10/31/06. This standard and our agency policy relative to this standard will be reviewed with all counselors at our next staff meeting on 10/12/06. The proper completion and timing of completion of the medication record will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. |
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 two of two records reviewed, #5 and 6.
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Plan of Correction
Our facility will be in full compliance with this standard by 10/31/06. This standard and our agency policy relative to this standard will be reviewed with all counselors at our next staff meeting on 10/12/06. The proper completion and timing of completion of aftercare plans will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
A discharge summary was missing in one of two records reviewed, #5.
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Plan of Correction
Our facility will be in full compliance with this standard by 10/31/06. A review of the necessity for completing a Discharge Summary as well as the appropriate timetable for such will be conducted at our next staff meeting on 10/12/06. The proper documentation of such wiill begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. |
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 information was not documented in two of two records reviewed, #5 and 6.
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Plan of Correction
Our facility will be in full compliance with this standard by 10/31/06. A review of the necessity for gathering follow up information as well as the appropriate timetable for such will be conducted at our next staff meeting on 10/12/06. The proper documentation of such wiill begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. |