INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 27, 2006 through March 28, 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 April 27, 2006.
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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 2 has not completed the required core curriculum training for clinical supervisors.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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 policies and procedures for the development plan does not include the timeframes for the completion of the needs assessment, the overall training plan, the training feedback, and the annual evaluation of the training plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Quarterly drug storage area inspections have not been documented by Diamond Pharmacy as per the agency's policies and procedures.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations were not evaluative. The evaluations were more of a detailed summary of the client's history along with direct observations by the counselor but with no clinical assessment.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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 previously stated goals in three of four clinical records, numbers, 2, 3, and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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 was not consistent with the current practice for the program.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |