INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23, 24 and 25, 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
A space heater was observed in an office in the billing department.
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Plan of Correction
All staff have been informed not to have space heaters in the facility. A corrective action plan was given to the staff member who had a space heater in her office. Space heater was removed and staff was again instructed to not have space heaters in the facility. During routine safety rounds, security will inspect each office for compliance with above directive. Program Director and/or Assistant Program Director will ensure that corrective actions are taken. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Documentation of fire extinguisher training was not provided for 14 of 40 employees, # 9, 10, 14, 15, 16, 17, 18, 19, 20, 21, 32, 35, 36 and 40.
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Plan of Correction
Staff named were trained and documentation is provided in the files. Since January 2007, training on fire extinquisher is done when new hire work is completed. The training specialist and HR representative will ensure that all employees have fire extinguisher training within seven days of start date. ASU director will oversee and ensure that corrective actions are implemented. |
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
Documentation of emergency training was not provided for 14 of 40 employees, # 9, 10, 14, 15, 16, 17, 18, 19, 20, 21, 32, 35, 36 and 40.
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Plan of Correction
Documentation of emergency training for staff will be provided in all training files. From employees start date, the employee will be instructed to meet with HR representative and Training Specialist. They will make sure that the training takes place and the training certificate is documented in credential/training files. Program Director, Assistant Program Director, HR representative and Training Specialist will ensure that corrective actions are taken. |
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
Goals did not include measurable action steps in 14 of 28 records reviewed, # 2, 3, 6, 8, 9, 11, 12, 17, 20, 21, 22, 25, 27 and 28.
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Plan of Correction
Staff will be trained by supervisors on how to complete long and short term goals which are measurable. |
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 an assessment of the client's progress in relationship to the previously stated goals in 16 of 28 records reviewed, #2, 3, 4, 5, 6, 7, 9, 11,17, 22, 23, 24, 25, 26, 27 and 28.
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Plan of Correction
Staff will be trained on how to complete treatment plan updates to include assessment of the client's progress from the previous treatment goals. Staff will be trained by supervisors. |
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 include the data and assessment portion of the note in 14 of 28 records reviewed, #2, 3, 4, 5, 6, 9, 11, 13, 15, 17, 19, 20, 25 and 27. Also, individual sessions are not being conducted as stipulated in the client's treatment plans.
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Plan of Correction
Staff will be retrained by supervisors on progress note writing. The training will include what should be stated in the data, assessments and plan portions of the note. The training will also include the importance of conducted individual sessions as indicated on the treatment plan. Staff will be trained on to put a note to chart if a client does not appear for his/her individual session. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Follow up information was not documented in eight of 18 records reviewed, #30, 32, 33, 34, 37, 43, 45 and 46.
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Plan of Correction
All follow up care for clients will be documented in the clients chart. Additionally, supervisors will train the staff in conjunction with the training coordinator on a follow up documentation training. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Performance evaluations are to be done semiannually on counselor assistants. Employee # 21 only had one evaluation since his date of hire, March 13, 2006.
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Plan of Correction
Counselor assistants will have two evaluations per year as directed by the regulations. Supervisors will be trained by the Assistant Program Director regarding the evaluations. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Weekly supervision notes from May 10, 2006 to present did not provide adequate evaluation and planning for the counselor assistant, #21. The supervision notes simply described what occurred in the treatment session and did not focus on the strengths and areas in need of improvement of the counselor assistant.
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Plan of Correction
Supervisors will be trained that when providing weekly supervision notes on counselor assistants to accurately document the strengths and areas of improvement and progress of the counselor assistant. For the next nine months, the supervision sessions for employee #21 will focus on his strenghts and areas that need improvement. The notes will also include progress in all competencies that he has mastered. This will be an ongoing process with employee #21 until nine months are completed. Program Director, Assistant Program Director and HR representative will ensure that the corrective action is implemented |