INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22 through 23, 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 September 21, 2006.
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Plan of Correction
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
The female bathroom did not have a functional exhaust fan.
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Plan of Correction
The landlord was informed of the non-functional exhaust fan and the fan was fixed by 9/5/06. |
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
Psychosocial evaluations did not address client assets/strengths, coping/defense mechanisms, support systems and negative factors that may inhibit treatment in one of one client record reviewed, #1.
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Plan of Correction
The identified client record did not contain the narrative biopsychosocial summary that includes specific references to client strengths, coping/defense mechanisms, support systems and factors that would either inhibit or support treatment.
The assessment process, including the routine use of this document, was reviewed with the counselor. The clinical supervisor will monitor compliance with completion of this documentation. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Treatment plan goals did not contain measurable action steps in two of two client records, #1 and #2.
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Plan of Correction
Follow-up training to be provided with respect to writing measurable action steps as part of all treatment plans.
The clinical supervisor will monitor compliance with completion of this documentation. |
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
Treatment plan updates did not include a review of progress on previously stated goals in two of two client records reviewed, #1 and #2.
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Plan of Correction
The agency has a policy that client progress must be documented on a Progress Review form at the time of developing new treatment plans.
This procedure was reviewed in detail with the counselor in the project. The clinical supervisor will monitor compliance with completion of this documentation and will be discussed periodically within supervision. |
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
Progress notes for individual sessions did not address the plan for the next session in two of two records reviewed, #1 and #2.
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Plan of Correction
The agency has policy regarding the use of a DAP format for progress notes. The agency defines the Plan section of progress notes as requiring detailed information regarding the planned clinical follow-through for the client.
The policy was reviewed with the counselor in the project through follow-up training. The clinical supervisor will monitor compliance with completion of this documentation and will be discussed periodically within supervision. |