INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24, 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 15, 2007.
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Plan of Correction
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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
Training feedback forms were not consistently documented in both of the employee records reviewed, (employee records #1 and 2).
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Plan of Correction
The Staff Development policy and procedure has been updated as follows:
Evaluations of all staff development/inservices activities must be completed by all participants. Internal training evaluations must be completed and submitted to the Staffing Coordinator within five (5) business days of the on-site training. Evaluations of external or off-site trainings and seminars must be completed by the participant and submitted to the Staffing Coordinator within 30 days of attending the training.
Evaluations forms will be distributed by the Staffing Coordinator to all participants at the beginning of all on-site trainings and will be distributed to off-site participants when notified they attended a training.
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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 plan in one of four records reviewed, ( #2), failed to document employee input in the development of the training plan.
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Plan of Correction
The distribution of Training Needs Assessment will be included with all probationary evaluations and annual evaluations to ensure receipt of employee input. |
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 conduct case consultations in a timely manner to discuss problematic clients who were not responding to treatment strategies in two of six records reviewed, #6 & 7.
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Plan of Correction
When a client is failing to make progress relative to treatment plan objectives and treatment interventions, the primary therapist will be expected to discuss the case at a weekly peer-to-peer review session. Alternative treatment strategies will be discussed and documented for inclusion on a written case consult form. The practice of recording all case consultations which are occurring in peer-to-peer discussions will be implemented and monitored by the Facility Director. |