INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 29, 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 January 2, 2007.
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Plan of Correction
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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 documented for two of three employees, # 2 and 3.
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Plan of Correction
Project Director will conduct staff meeting and train all staff in use of fire extinguisher, review emergency procedures and assign tasks during an emergency.
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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 documented for two of three employees, # 2 and 3.
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Plan of Correction
Project Director will conduct staff meeting and train all staff in use of fire extinguisher, review emergency procedures and assign tasks during an emergency.
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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
Psychosocial evaluations did not include an assessment of the client's assets/strengths, support systems, coping mechanism, clients attitude towards treatment and negative factors that may inhibit treatment in four of four records reviewed, #1, 2, 3 and 4.
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Plan of Correction
Employees at the York site will be provided written feedback of the BDAP licensing review.
Project Director will conduct staff meeting and emphasize the expectation of documenting these areas.
Clinical supervisor will emphasize in 1-1 supervisory session, the expectation of documenting these areas.
AHCS UR will check for documentation and report results to supervisor and clinician.
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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 did not include goals with realistic time frames and support services in two of two records reviewed, #3 and 4.
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Plan of Correction
Employees at the York site will be provided written feedback of the BDAP licensing review.
Project Director will conduct staff meeting and emphasize the expectation of documenting these areas.
Clinical supervisor will emphasize in 1-1 supervisory session, the expectation of documenting these areas.
AHCS UR will check for documentation and report results to supervisor and clinician.
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