INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26 through 27, 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 August 18, 2006.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Feedback forms were not completed in six of six personnel records reviewed, # 1, 2, 3, 4, 5 and 6.
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Plan of Correction
Director will review policy with staff, including personnel #1,2,3,4,5 and 6, to ensure thorough understanding of policy. Training feedback forms will be submitted to human resources personnel within 7 days of attending training. Director will monitor for compliance on an on-going basis. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Employee number #4 did not receive the required HIV/AIDS and TB/STD training in the required time period.
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Plan of Correction
Director will address missing training requirment with employee #4, and refer to HIV/AIDS and TB/STD training. Employee #4 will receive these trainings at the the next available offering, not to exceed 60 days. All future employees will receive required training within required time period. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Documentation did not reflect that a copy of the consent was offered to the client in five records, # 2, 3, 4, 5, and 6.
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Plan of Correction
Director will review policy with entire staff within one week. Staff will be advised to indicate a copy of consent was offered to each client, by marking "accepted" or "refused" copy on every consent form. Director will monitor for compliance on an on-going basis. |
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
Evaluations did not address assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment in four of six client records reviewed, # 1, 2, 3 and 6.
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Plan of Correction
As discussed during the survey, Director will modify existing Evaluation form within 7 days to include the following areas: assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment. This information is currently contained on the Client History form. Once this modification is complete, Director will review with staff, and staff will be instructed to institute this change immediately. Director will monitor for compliance on an on-going basis. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The type of service was missing on treatment plans in three of six client records reviewed, # 2, 4 and 5.
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Plan of Correction
Director will review policy with entire staff within 7 days. Staff will ensure type of service being provided is clearly visible on all treatment plans. Director will monitor for compliance on an on-going basis. |
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 assess the client's progress in relationship to the previously stated goals on the treatment plan in three client records reviewed, # 4, 5 and 6.
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Plan of Correction
Director will modify the format of the existing treatment plan within 7 days to allow for more space to thoroghly document client progress. Director will inform staff of this modification, explain the purpose and review the policy to ensure full understanding of the expectation of this policy. Staff will be responsible for thoroughly representing client's progress from the previous plan on each treatment plan. Director will monitor on an on-going basis for full compliance. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Case consultations were missing in three of six client records reviewed, # 4, 5 and 6.
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Plan of Correction
Effective immediately, Director will ensure timely completion of case consultations for all clients during clinical supervision meetings. Director will monitor for compliance on an on-going basis. |
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
Aftercare plans were missing in three of three client records reviewed, # 6, 7 and 8.
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Plan of Correction
Director will review aftercare policy with staff within 7 days to ensure full understanding of this policy. Staff will be responsible for documenting aftercare by completing the aftercare plan with clients and submitting it to the client chart. Director will monitor on an on-going basis for full compliance. |
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 as per facility's policy and procedure in three of five client records reviewed, # 7, 8 and 10.
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Plan of Correction
Director will amend policy and procedure within 7 days to state documentation of follow-up information will be reflected on a narrative note which shall be completed by the counselor and included in the client chart. A meeting will be held with staff to advise of this modification and instruct staff to begin implementing this change immediately following this meeting. Director will monitor for compliance on an on-going basis. |