INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19, 2007 through March 21, 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 April 19, 2007.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
The procedures for the creation of the program's overall training plan, annual evaluation of prior year's training plan, and the assessment of staff training needs were not congruent with the current practice of the program.
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Plan of Correction
The agency's 704.11(a)1-4 written standards did not clerarly define the staff development program in current practice. The overall Training Plan for the agency's programs did not specifically list action plans for trainings needed and planed for the training year.
All agency programs are in full compliance as of 3/21/2007. The next revised Training Plan will be submitted by October 2007. The agency's Training Track spring brochure, indicating specific scheduled trainings, will serve as the current training plan until the end of this fiscal/training year (June 30,2007).
The agency's 704.11(a)1-4 were rewritten and approved by Treatment Trends, Inc. administration and DDAPL evaluater on 3/21/2007. They clearly define current procedures for assessment of staff training needs, the development of the Training Plan, Feedback on training, and Annual Evaluation of previous year's training. See attached revised 704.11(a)1-4. The Training Coordinator has been informed of the revised procedure and content for the yearly overall Training (action) Plan. The new 2007/08 Training Plan will be developed by the Training Coordinator during July 07 thru September 07 (with input from the Training Planning Committee - who have analyzed staff training needs and feedback from the prior year's trainings). The Training Plan will be submitted by Oct 2007 for immediate implementation.
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704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
The client to counselor ratio is 9:1.
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Plan of Correction
The agency's expectations are to fulfill the 704.12(a)(3)(i) standards as written. One full-time counselor left the employment of Keenan House in mid-March 2007 thus causing our program to exceed the client/staff and client/counselor ratio (8:1) during primary care hours. The ratio upon inspection was 9:1 due to the vacant counselor position.
Recruitment has been ongoing since the evacuated the counseling position. We seek to fill this position with an appropriate candidate and be in full compliance by May 20, 2007.
Keenan House has been activly recruiting candidates for the counseling position through newspaper and web based advertising since the position became vacent. We are seeking an appropriately educated individual with experience reflecting D&A/CJ exposure. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Treatment plan updates were either missing or completed later than 30 days in one of seven client records reviewed, #5. Treatment plan updates did not include a review of progress on all previously stated treatment plan goals in three of seven client records reviewed, # 1, 2, and 4.
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Plan of Correction
In addition to the staff responsibility to ensure that all paperwork is completed in a timely manner, the Clinical Supervisor keeps a running tab on all paperwork deadlines including the completion of treatment plan updates which are to be updated at least every 30 days. Complying with standard 709.52(b) had been a difficulty for one staff member who on occasion missed the 30 day deadline for treatment plan updates. His probationary status was extended due to ongoing difficulty. With adequate supervision, this deficiency was resolved.
In addition, some staff were unclear regarding how treatment plan goals should be addressed thus some updates did not include a review of progress on all previously stated treatment plan goals.
Staff is expected to comply with standard 709.52(b)by April 15, 2007.
The Clinical Supervisor will continue to tabulate due dates of all paperwork, including paperwork necessary to comply with standard 709.52(b). Moving forward, any counselor who is not meeting the standard will be addressed in supervision to detail problem areas tha may include but is not limited to time management and/or organizational skills. Probationary status may be extended as in this case or training may be required to help support counselors.
All treatment updates are reviewed by the Clinical Supervisor. The Clinical Supervisor will ensure tha each goal previously noted in a treatment plan is addressed in the update. |