INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted May 30 to June 1, 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 July 2, 2007.
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Plan of Correction
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Training was not documented for some staff (employee records #3, 5, 10). This training, as with the fire extinguisher training, may be included in the employee orientation, but must occur no later than seven days from the date of employment.
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all Fire Safety requirements. A staff meeting was held on June 12, 2007 to review fire extinguisher training and emergency procedures. In addition, training on emergency procedures has been added to the employee orientation material. The Executive Director, William Knecht, will oversee this and make sure that all staff are trained. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories lacked sufficient detail in each of the client records reviewed. Personal histories should collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated.
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all client record keeping requirements. Staff have been retrained on proper completion of psychosocial histories and evaluations. In addition, supervisors have been re-trained to monitor client psychosocial histories and evaluations to assure that they will be completed in their entirety and contain all of the required information, specifically including personal histories, detailed clinical impressions, assessment of strengths and weaknesses, support systems, and client coping mechanisms. The evaluations will provide a composite picture of the individual in relationship to collected historical information. The executive director, William Knecht, will oversee the clinical supervisors to assure that this is completed. |
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
The psychosocial evaluations failed to include detailed clinical impressions and opinions regarding the client's problems/needs, assets/strengths, support systems and coping mechanisms in 5 out of 12 client records reviewed, specifically #3, 4, 5, 8 and 11. The evaluation was missing in client record # 7.
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all client record keeping requirements. Staff have been retrained on proper completion of psychosocial histories and evaluations. In addition, supervisors have been re-trained to monitor client psychosocial histories and evaluations to assure that they will be completed in their entirety and contain all of the required information, specifically including personal histories, detailed clinical impressions, assessment of strengths and weaknesses, support systems, and client coping mechanisms. The evaluations will provide a composite picture of the individual in relationship to collected historical information. The executive director, William Knecht, will oversee the clinical supervisors to assure that this is completed. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
The facility failed to include complete aftercare plans in client records #1 and 2. The aftercare plans did not include support services. The aftercare plans in client records #1 and 3 did not focus on sustaining and building on the progress achieved during treatment.
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all client record keeping requirements. Staff have been retrained on proper completion of aftercare plans. In addition, supervisors have been re-trained to monitor client aftercare plans to assure that they will be completed in their entirety and contain all of the required information, specifically including support services and focusing on sustaining the progress the client has achieved in treatment. The executive director, William Knecht, will oversee the clinical supervisors to assure that this is completed. |