INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 19, 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 May 18, 2007.
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Plan of Correction
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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 facility failed to consistently document treatment plan updates. Client record number 1 was missing one treatment plan update and client records number 4 and 5 did not have treatment plan updates.
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Plan of Correction
Clinical Director, Scott Carpenter, will retrain all facility staff on the appropriate completion of client treatment plans and treatment plan updates at the weekly clinical staff meeting on 5/1/07. Emphasis will be placed on protocols concerning the times frames for completion of each document. Clinical director will then monitor on a weekly basis beginning on 5/8/07 to ensure compliance. |
709.93(a)(5) LICENSURE Client records
709.93. 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:
(5) Progress notes.
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Observations
The facility failed to document group notes in 2 of 5 records reviewed. The majority of the group notes in client record numbers 1 and 5 had group notes that were identical in content with the only difference being the date of service.
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Plan of Correction
Clinical Director, Scott Carpenter, will retrain all facility staff on the appropriare completion of progress notes at the weekly clinical staff on 5/1/07. Emphasis will be placed on the appropriate completion of client group progress notes as well as individual client progress notes. Clinical director will monitor on a weekly basis beginning on 5/8/07 to ensure compliance. |