INITIAL COMMENTS
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This is a report of the on-site licensure renewal inspection conducted on July 25, 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 23, 2007.
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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 facility failed to document an assessment of staff training needs in one of three employee records reviewed, # 3.
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Plan of Correction
Our project will be in full compliance with this standard by September 1, 2007. Our facility uses a questionnaire, which is completed by each employee every year. The proper completion of this questionnaire, as well as the standard will be reviewed with the employee mentioned. This will be done by the Clinical Supervisor in individual supervision. The questionnaire will then be fully and properly completed for each of these employees. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to ensure feedback forms were completed for training attended in one of three employee records reviewed, #3.
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Plan of Correction
Our project will be in full compliance with this standard by September 1, 2007. Our project uses a feedback form, which is to be completed by each employee for every training which is attended. The proper completion of this form, as well as the standard will be reviewed with the employee mentioned. This will be done by the Clinical Supervisor in individual supervision. The feedback forms will then be fully and properly completed for each training that this employee attended. |
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 facility failed to document an individual training plan in one of three employee records reviewed, # 3.
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Plan of Correction
Our project will be in full compliance with this standard by September 1, 2007. Our facility uses a questionnaire, which is to be completed by each employee every year. The proper completion of this questionnaire, as well as the standard will be reviewed with the employee mentioned. This will be done by the Clinical Supervisor in individual supervision. The questionnaires will then be fully and properly completed by the employee in collaboration with the Clinical Supervisor. Additionally, we have been working with our Licensing Specialist to modify and improve our questionnaire to more fully comply with this standard. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
The facility failed to document case consultations involving more than one clinician in three of five client records reviewed, #1, 2 and 5. Case consultations were completed by the primary counselor with no evidence of a consultation with other representatives from the facility.
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Plan of Correction
Our facility will be in full compliance with this standard by 9/30/07. This standard and our agency policy relative to this standard will be reviewed with all counselors at our next staff meeting on 8/21/07. The proper completion of the case consultation will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. |