INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26, 2007 through March 27, 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Employee number 3 has not completed the core curriculum training in clinical supervision.
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Plan of Correction
The 5 day training required by 704.6 (C) was last offered in early October 2006 for 15 individuals, in the far western region of the state. This is the only time it was offered anywhere in the state to date this year. As a corrective action, the Program Director will continue to check weekly the BDAP Training Management System and register employee #3 to attend. Please note as part of this corrective action plan that this training could fill up in less than one day with such limited availability to a mandated training not currently permitted to be offered in any other manner than through a single BDAP approved trainer. |
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 clearly define the staff development program in current practice. The overall Training Plan for the agency's programs did not specifically list action plan for trainings needed and planned for the training year. All agency programs are in full compliance as of 3/21/07. 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 evaluator on 3/21/07. They more 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. 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 Sept. 07 (with input from the Training Planning Committee - who have analyzed staff training needs and feedback from the prior year's training). The Training Plan will be submitted by Oct. 2007 for immediate implementation. |
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 did not include a review of progress on all previously stated goals in four of five client records reviewed, # 1, 2, 3, and 5.
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Plan of Correction
Treatment plans reviewed under 709.52. Treatment and rehabilitation services (b) did not consistently include a review of progress on all previously stated goals. To resolve the deficiency, the Program director will complete a review of the requirements with the clinical team within 30 days. The Clinical Director will randomly review 10 client charts a month over the course of the year to review treatment plans and insure compliance with this standard. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Discharge summaries did not include the reason for this treatment experience in three of five client records reviewed, # 8, 9, and 10. Additionally, discharge summaries did not provide the treatment services offered to the client in four of five client records reviewed, # 6, 7, 8, and 10.
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Plan of Correction
In regard to standard 709.53. Client records. (a) Discharge summaries reviewed did not consistently include the reason for this treatment experience. To resolve the deficiency, the Program director will complete a review of the requirements with the clinical team within 30 days. The Clinical Director will randomly review 10 client charts a month over the course of the year to review treatment plans and insure compliance with this standard. Monthly review will start May 27, 2007. |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
The follow-up policy does not address follow-up attempts for client's who are discharged from treatment unsuccessfully and are not referred to another treatment facility.
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Plan of Correction
The policy for the program did not fully comply with 709.54. Project management services (C). The Program Director will be responsible for re-writing and implementing the plan to include attempted contact for individuals who leave treatment against facility advice and who are asked to leave treatment as non-compliant with facility rules and policies. The new plan will be written and in place within 45 days of this corrective action plan. |