INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 1, 2006 through May 3, 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 June 6, 2006.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
The assessment of training needs forms were not completed as per agency policy for employee numbers 1, 2, 9, 13 and 14.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The individual training plans were not completed for employee numbers 1, 2, 9, 13 and 14.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
The financial statement for the July 2004 through June 2005 fiscal year did not include a statement of financial expenses for that year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The goals and objectives for the July 2005 through June 2006 fiscal year did not identify available resources that would help to achieve the outlined goals and objectives.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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 evaluations did not consistently address client problems/needs, assets/strengths, support systems and negative factors that may inhibit treatment in 9 of 14 clinical records reviewed, numbers 3, 5, 6, 7, 9, 10, 11, 13 and 14.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The goal statements in the treatment plans were not consistently supported by their corresponding action steps in 8 of 13 clinical records, numbers 4, 5, 6, 8, 10, 11, 12 and 13. Several of the action steps reviewed were general in their scope and were more appropriate as goal statements themselves.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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 updates did not consistently address the specific progress made by the client within the past 60 days as it relates to the prior treatment plan goals in nine of eleven clinical records reviewed, numbers 1, 3, 4, 5, 6, 8, 10, 11 and 13.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
The goals identified in the aftercare plans were general and contained inconsistent timeframes in four of four clinical records reviewed, numbers 8, 9, 13 and 14. Three of four clinical records had aftercare plans that did not address any support services for the client to access after discharge, numbers 8, 9 and 14.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |