INITIAL COMMENTS
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This report identifies the findings of an on-site complaint investigation conducted on March 14, 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 April 12, 2007.
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Plan of Correction
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704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
The facility exceeded the required 8/1 client/counselor ratio as at the time of the investigation the ratio was 10/1.
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Plan of Correction
Colonial House, Inc has been aware of this issue and has taken steps to remedy this deficiency. We had advertised and hired a FTE who was to start on 3/26/07. This FTE subsequently turned down the offer of employemnt. We have found it very difficult to find qualified, experienced candidates. We have advertised extensively and are again reviewing resumes on file. We have offered interviews to three applicants and we conducted interviews the week of 4/2/07. We did make an offer of employment which was accepted and this individual will begin work the week of 4/23/07.
In addition, we have taken steps to make the benefit package more attractive by raising the starting salary for counselors and offering a vision plan.
Our marketer has visited the local colleges or spoken to their career placement centers about posting job opportunities at Colonial House.
We currently have 3 FTEs and our CEO has taken on more clinical responsibilities (20 hours per week). Our ratio as of 4/12/07, is 8.57 to 1 which is down from the 10 to 1 ratio at the time of the visit. We will continue to monitor admissions and the ratio. Compliance to be achieved by 4/30/07. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Although the facility is securing signed consents to release information, the documentation on record does not consistently indicate what information is being shared. This is specifically true for agencies and individuals identified on the "Client Service Calls" log. The content of any and all correspondence, whether written or verbal, needs to be clearly documented.
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Plan of Correction
This issue was addressed by the Clinical Supervisor at the clinical staff meeting held on 3/30/07. The clinical team was advised that when documenting communication on the "Client Service Call" log a brief description of the call needs to be documented on the log to insure that what has been communicated is within the scope of the consent and the clinet's confidentiality is not breached. The Director of Operations revised this log to allow for this documentation. The new form was distributed on 4/3/07.
The CLinical Supervisor will monitor for future compliance. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
The chart reviewed during this investigation did not have an appropriately individualized treatment plan. The facility identified a treatment issue at intake and subsequently made a referral to an outside professional for an evaluation. According to the written individual progress notes the issue was addressed in therapy sessions, yet the issue was not included on the client's treatment plan.
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Plan of Correction
The Clinical SUpervisor addressed this finding at the clinical staff meeting held on 3/30/07. The team was advised that what is addressed and documented on the "individual progress note" must relate back to the treatment plans. The progress note was updated by the Director of Operations to include a place to reference the appropriate section of the treatment. The Clinical Supervisor also reminded the the clinical team that when any issues arise during individual sessions that do not correspond to a treatment plan issue the counselor needs to complete a treatment plan update.
The Clinical Supervisor will monitor for future compliance. |