INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25 - 26, 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 17, 2007.
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Plan of Correction
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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 facility failed to provide individual training plans for both staff members, refer to personnel records #1 and #2.
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Plan of Correction
The project was not in compliance with the standard because their was confusion between the individual training plan and the agency training plan leading to oversight and not completing an individual training plan for record #1. Furthermore, the project failed to be careful to details needed in the individual training plan for record # 2. Individual training plans were constructed on 7/30/07 for records # 1 & #2. The project has decided to make the individual training plans like the agency training plan according to the calendar year, January through December rather then hire date to eliminate confusion and oversight. The supervisor will meet with the employees of the project in December of the previous year to discuss and construct the employee's individual training plan for the coming year. The supervisor will also pay close attention to detail when constructing the individual training plan such as goal, specific training topics and specific training companies. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
The facility failed to provide informed consent to clients in Client records #3, #4, and #5.
Client record #4 did not identify Family Services of Warren County, Inc as the organization that will disclose the information. Client records #5 included a release of information that did not identify the person or agency to whom the information would be released. Client records #3, #4, and #5 included the full names of the group treatment participants on the group progress notes filed in the client record of each of the participants, violating the confidentiality of the other participants.
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Plan of Correction
Confidentiality was compromised due to a lack of paying careful attention to details and being careless in completing the release of information. Furthermore, the full names of the group treatment participants happened because of not being thorough in considering the circumstances. Additionally, the clinical supervisor failed to provide quality assurance with client's records on a regular basis to assure compliance with confidentiality rules. Records #3, #4 and #5 are currently in compliance with confidentiality rules as of 7/30/07. Clinicians will take extreme care in paying attention in completing the release of information appropriately in order to maintain the client's confidentiality. Furthermore, group treatment progress notes will not contain the full names of each participant in each client's records. Finally, the clinical supervisor will perform quality assurance of client's records on a regular basis, once a month, to assure compliance with confidentiality. |
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 facility failed to provide psychosocial evaluations for client records #3, #4, and #5. Three of six client records reviewed were missing psychosocial evaluations.
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Plan of Correction
The compliance standard of completing psychosocial evaluations on each client was not met due to oversight by the clinician, however, this also could have been resolved if the clinical supervisor performed regular quality assurance on client's files to assure compliance of licensure requirements. Records #3, #4 and #5 have a completed psychosocial evaluation and signed by the medical director and the clinical supervisor as of 8/7/07. Clinicians will need to pay careful attention to complete the psychosocial evaluations by the 4th session according to the agency's clinical procedures. Finally, the clinical supervisor will perform quality assurance of client's records on a regular basis, once a month, to assure compliance with licensure requirements for client's records. |