INITIAL COMMENTS
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This report identifies the findings of an on-site complaint investigation conducted at your facility on August 18, 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 October 3, 2006.
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Plan of Correction
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
The facility's current practice of calling a client's insurance company before a written consent to release information is signed by the client is not an informed and voluntary consent.
Progress notes for group counseling sessions contained both first and last names of the clients in two records reviewed.
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Plan of Correction
Release forms were signed during admissions rather prior when insurance company was called. Admissions staff have been informed to obtain release prior to insurance call. Staff person completing evaluation now obtains consent form and is signed prior to phone call to insurance company for admission approval. Facility and Admission Director will monitor to ensure compliance.
Counselors were informed by Facility Director that group notes may ONLY contain first name and last initial. Compliance will be monitored via chart checks. |
709.32(c)(6) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(6) Inventories.
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Observations
The facility's policy and procedure states that inventories are completed both monthly and quarterly on all stock medications. The documentation for inventories is only completed on a quarterly basis.
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Plan of Correction
Policy was inconsistent with time frame for inventory. Policy has been revised to indicate bi-monthly inventory for all stock medications and will be recorded by a designated nursing staff member. Nursing supervisor will monitor for compliance. |
709.62(c)(2)(i) LICENSURE Orientation Proj policies
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(i) Project policies, which include the following:
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Observations
The facility's current practice of having new clients sit in the lobby for up to two to three hours while insurance eligibility is determined needs to be changed. The facility should develop a procedure to complete this process in a timely manner while engaging client's in treatment.
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Plan of Correction
Patient are now signing consent for insurance immediately upon arrival to decrease wait time for eligibility. Appointment times are designated by Admissions to ensure immediate evaluation to decrease wait time. Insurance companies are informed that admission is an urgent matter to expedite admission process and approval. Admissions Director will monitor and track improvement in wait time and treatment engagement. |