INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 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 16, 2006.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
The overall training plan for addressing training needs for the 2006 training year, January through December, was missing.
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Plan of Correction
The Project Director will create the training plan. It will be completed annually, and be presented to the managers annually. |
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
The feedback for training attended by employee number 16 were missing for the 2005 training year.
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Plan of Correction
Paoli's administrative assistant will create an access database which will track employee progress toward training goals as well as whether we have the documentation. She will give this report quarterly to the Project Director as well as the managers. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
The annual evaluation of the overall plan was missing for the 2005 training year.
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Plan of Correction
An overall evaluation for the 2005 training plan was compiled by the Project Director, using the individual evaluations from each of the therapists. For 2006 Project Director will use the evaluations collected from each individual therapist to compile a summary of the overall evaluation of the training plan. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The project goals and objectives did not identify any available resources.
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Plan of Correction
The goals and objectives will be created each year by the Project Director who will ensure that they will include the available resources or responsible personnel.
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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
Parent/guardian signature lines were included on the consent to release information forms. Parental consent for disclosure of information is not mandated by state law and cannot be required.
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Plan of Correction
A new release form with parent signature removed was created |
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 did not assess the client's assets/strengths, support systems, coping mechanisms, and negative factors that may inhibit treatment in six of seven client records reviewed, # 1, 2, 3, 4, 5, and 7.
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Plan of Correction
Each site manager will have a staff training by September 15, 2006 which will address the following objectives:
Creating a treatment plan which has measurable goals, and a review process of those goals from previous treatment plans
Each staff person will submit 3 charts for review by October 1, 2006. The manager will review to verify completion of treatment plan updates as well as for content of update. Content should include a review of client's goals and action steps from the treatment plan.
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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 four of seven client records reviewed, # 1, 2, 3, and 7.
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Plan of Correction
Each site manager will have a staff training by September 15, 2006 which will address the following objectives:
Creating a treatment plan which has measurable goals, and a review process of those goals from previous treatment plans
Each staff person will submit 3 charts for review by October 1, 2006. The manager will review to verify completion of treatment plan updates as well as for content of update. Content should include a review of client's goals and action steps from the treatment plan.
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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 the client's progress of goals and action steps from the previous treatment plan in three of seven client records reviewed, # 1, 2, and 4.
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Plan of Correction
Each site manager will have a staff training by September 15, 2006 which will address the following objectives:
Creating a treatment plan update which has a review process of those goals and action steps from previous treatment plans
Each staff person will submit 3 charts for review by October 1, 2006. The manager will review to verify completion of treatment plan updates as well as for content of update. Content should include a review of client's goals and action steps from the treatment plan.
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