INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18 through 19, 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 October 19, 2006.
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Plan of Correction
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The personal histories did not address the family of origin in four of thirteen records reviewed, #1, 2, 4 and 7. The personal histories did not address the employment history in eight of thirteen records, #1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
Project was not in compliance with the standard due to agency form formatting problems and new untrained staff. An in-service facilitated by Division Director, will be held Friday, October 20, 2006 to address documentation of family of origin and employment histories. Ongoing training will be provided by the Gaudenzia Training Institute. Personal histories will be reviewed by Supervisors during individual supervision sessions, and monitored through our Continuous Quality Improvement program. Forms will be reviewed by Continuous Quality Improvement Committee. |
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 were missing a composite picture in five of thirteen records, # 2, 4, 6, 7 and 8. The psychosocial evaluations were missing coping/defense mechanisms in five of thirteen records, #1, 2, 5, 8 and 11.
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Plan of Correction
Project was not in compliance with the standard due to agency form formatting problems and new untrained staff. An in-service facilitated by Division Director, will be held Friday, October 20, 2006 to address Psychosocial evaluation composite picture and coping/defense mechanisms. Ongoing training will be provided by the Gaudenzia Training Institute. Psychosocial Evaluation composite picture and coping/defense mechanisms will be reviewed by Supervisors during individual supervision sessions, and monitored through our Continuous Quality Improvement program. Forms will be reviewed by Continuous Quality Improvement Committee. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The type of services was missing in six of thirteen records reviewed, #1, 2, 7, 8, 10 and 12.
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Plan of Correction
Project was not in compliance with the standard due to agency form formatting problems and new untrained staff. An in-service facilitated by G. Hannah, Ambulatory Division Director, will be held Friday, October 20, 2006 to address Treatment and rehabilitation service plan documentation of type and frequency of treatment and rehabilitation services. Ongoing training will be provided by the Gaudenzia Training Institute. Treatment and rehabilitation service plans will be reviewed by Supervisors J. Garland/W. Holloman, during individual supervision sessions, and monitored through our Continuous Quality Improvement program. Forms will be reviewed by Continuous Quality Improvement Committee. |
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 updates did not include a review of progress on previously stated goals in seven of thirteen records reviewed, #3, 5, 6, 7, 8, 9 and 10.
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Plan of Correction
Project was not in compliance with the standard due to agency form formatting problems and new untrained staff. An in-service facilitated by Division Director, will be held Friday, October 20, 2006 to address Treatment and rehabilitation service plan update review of progress on previously stated goals. Ongoing training will be provided by the Gaudenzia Training Institute. Treatment and rehabilitation service plan updates will be reviewed by Supervisors during individual supervision sessions, and monitored through our Continuous Quality Improvement program. Forms will be reviewed by Continuous Quality Improvement Committee. |