INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 10, 2007 through July 12, 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 5, 2007.
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Plan of Correction
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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 were historical rather than evaluative and failed to include clinical impressions regarding the client's problems/needs, assets/strengths, support systems and coping mechanisms in ten of ten client records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
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Plan of Correction
Will explore and schedule external technical assistance trainings on this item as well as internal staff trainings and staff development articles that will be provided regarding the documentation of clinical findings resulting from psychosocial evaluations. These assessments will address the individual's strengths, weaknesses, coping mechanisms and negative factors that may inhibit treatment or support systems. The Clinical Director will provide individual supervision and will monitor this area of content. Random, monthly chart audits by the Executive Director will ensure 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
The treatment plan update did not include an assessment of the client's progress in relationship to the stated goals in one of three records reviewed, #5. The treatment plan update was not completed within the required time frame in one of three records, #4. The treatment plan update was not documented in one of three records reviewed, #7.
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Plan of Correction
Staff training and individual supervision will be provided to the specific clinician identified regarding the specific documentation of type of services and frequency of services that are provided individually for clients and that such types and frequency of services are recorded on the treatment plans. Staff trainings, individual, group supervision as well as twice weekly team meetings will monitor treatment plan updates to ensure that client's progress in relation to stated goals is specifically addressed in the update. This monitoring will also address the standard of at least every 60 days. Random, monthly chart audits by the Clinical Director and Executive Director will ensure 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 failed to include goals and support services for clients in two of two client records reviewed, #7 and 10.
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Plan of Correction
Staff trainings, individual, group supervision and twice weekly clinical team meetings will monitor Aftercare Plans to ensure that specific individual's goals and support systems are identified and documented on the Aftercare Plan in the client record. Random monthly chart audits by the Clinical Director and the Executive Director will ensure compliance. |